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Presented  by 

Mrs  -    Fraiik  G.    Peirsol 


COLLEGE  OF  OSTEOPATHIC  PHYSICIANS 
AND  SURGEONS  •  LOS  ANGELES,  CALIFORNIA 


PRACTICAL  TREATISE 


DISEASES  OF  WOMEN. 


ILLUSTRATED   BY 


Colored  Jlates  and  J^umcFous  Wood  Engravings. 


BY  JOHN  M.  &CUDDER,  M.  D., 

PROFESSOR  OF  THE   THEORY    AXD    PRACTICE   OF   MEDICIXE  IX    THE    ECLECTIC    MEDICAL 

INSTITUTE,   CIXCIXXATi;    FORMERLY    PROFESSOR   OF   OBSTETRICS   AND   DISEASES 

OF   WOMEX   AND   f'HILDRKX    IX   THE    SAMK  ;    AUTHOR  OF  THE    ECLECTIC 

PRACTICE  OF   MKDICIXK,    KCLEC'TIC   MATERIA    MEDICA,    ETC. 


WITH    A   PAPER 


ON  THE  DISEASES  OF  THE  BREASTS.  BY  ROBERT  S.  NEWTON,  M.  D. 

LATE  PROFESSOR  OF  SURGERY   IX  THE    ECLECTIC    MKDICAL    INSTITUTE,    OF  CINCINNATI, 


Fifteenth  Edition,  Thoroughly  Revised. 


CINCINNATI: 

JOHN   M.  SCUDDER,   PUBLISHER. 
1891. 


tup  \ 


Entered,  according  to  act  of  Congress,  in  the  year  1378,'  by 

JOHN    M.    SCUDDER,    M.  D., 

In  the  Clerk's  Office  of  the  District  Court  of  the  United  States  for  the  Southern 

District  of  Ohio. 

Entered,  according  to  act  of  Congress,  in  the  year  1891,  by 

JOHN  M.  SCUDDER,  M.  D., 
In  the  office  of  the  Librarian  of  Congress,  at  Washington,  D.  C. 


PREFACE. 


IN  commencing  the  practice  of  Medicine  my  attention  was  espe- 
cially drawn  to  the  study  of  those  diseases  peculiar  to  women — 
diseases  of  the  uterus  and  its  appendages,  from  the  proportionally 
large  number  of  cases  of  these  disorders  in  which  I  was  consulted. 
It  was  evident  that  my  success  in  general  practice  depended,  in  a 
great  degree,  upon  the  success  of  my  practice  in  these  special  forms 
of  disease,  and  yet,  in  the  literature  of  the  Eclectic  branch  of  the 
profession,  I  could  find  nothing  that  could  be  considered  a  sufficient 
guide  to  the  young  practitioner.  It  is  true  that  we  have  a  mass  of 
information  scattered  through  the  pages  of  our  medical  journals,  and 
it  is  equally  true,  and  can  not  be  disputed,  that  the  Eclectic  practice 
is  far  more  successful  in  these  diseases  than  the  Allopathic  or  old- 
school  practice  ;  yet  this  information  required  to  be  collected  and 
arranged  before  it  could  be  available  for  the  student  or  general  prac- 
titioner. I  also  found  that  in  those  articles  which  have  been  published 
on  this  subject,  that  the  pathology  of  these  morbid  processes  was 
scarcely  referred  to  —  all  that  was  given  being  the  arbitrary  name  of 
the  disease,  the  general  symptoms,  and  the  treatment,  which,  though 
successful,  wras  not  founded  upon  the  pathological  character  of  the 
diseased  action. 

On  examination  of  the  numerous  Allopathic  wTorks  on  this  subject, 
I  found  that  the  pathology  of  uterine  disease  had  been  carefully  and 
successfully  studied,  and  that,  in  this  respect,  this  branch  of  medical 
science  was  at  least  equal,  if  not  in  advance  of  the  general  practice 
of  medicine :  and  yet,  with  this  accurate  knowledge  of  the  nature  and 
character  of  the  diseased  actions,  their  treatment  was  far  less  success- 
ful than  our  own,  so  far  as  medicinal  agents  were  used  for  the  cure, 
but  where  operative  interference  was  required,  nothing  more  could  be 
desired  than  was  given  in  these  works. 

(3) 

^  -2  v  •-_-  /- 


4  PREFACE. 

From  this  investigation,  commenced  for  my  own  benefit,  the 
present  work  has  grown.  For  the  description  and  pathological 
character  of  the  diseases  described  in  the  following  pages,  I  am 
principally  indebted  to  old-school  authorities;  but  the  practice  is 
strictly  Eclectic,  ever}- measure  recommended  having  been  fully 
tested  by  mj'self  or  by  our  most  successful  Eclectic  practitioners. 


PREFACE  TO  THE  EIGHTH  EDITION. 


For  twenty  years  this  work  has  been  before  the  professionr 
and  the  fact  that  it  has  passed  through  seven  editions  is  its  best 
recommendation  to  new  readers.  In  some  respects  it  urged  a 
departure  from  the  ordinary  practice,  especially  in  displacements 
of  the  uterus,  wholly  discarding  pessaries.  Time  has  proven  the 
truth  of  these  views,  and  a  large  number  of  the  best  physicians 
have  adopted  them. 

This  edition  lias  been  thoroughly  revised,  especially  in  the 
treatment  of  disease  and  use  of  remedies.  All  the  new  means 
are  described,  and  the  indications  for  the  selection  of  individual 
remedies  pointed  out.  In  the  future  we  will  depend  more  and 
more  upon  general  treatment,  and  the  direct  action  of  remedies, 
and  will  find  in  consequence  that  the  practice  will  be  pleasanter 
both  to  physician  and  patient,  and  more  successful. 

CINCINNATI,  October  10th,  1877. 


PREFACE  TO  THE  FOURTEENTH  EDITION. 


In  re-reading  this  work  I  find  but  few  changes  necessary.  As 
time  passes  the  truth  of  <:  specific  medication  "  is  more  clearly 
established,  and  the  selection  of  remedies  in  diseases  of  women 
is  shown  to  be  based  upon  the  same  principles  as  in  ordinarj7-  dis- 
eases. Given,  the  indications  for  a  remedy,  and  its  action  is  as 
certain  here  as  elsewhere.  Conversely,  if  medicines  are  not  so 
selected,  the  action  will  be  as  uncertain  as  in  other  cases. 

CINCINNATI,  October  10th,  1886. 


CONTENTS. 


PREFACE, 3 

INTRODUCTION, 17 


CHAPTEE  1. 
ANATOMY  OF  THE  FEMALE  ORGANS  OF  GENERATION. 

Preliminary  Observations, 33 

Classification  of  the  Organs  of  Generation, 3-i 

Mons  Yeneris, 34 

Labia  Majora, 35 

Nymphse, 36 

Clitoris, 37 

Yestibule, • 38 

Meatus  Urinarius 38 

Hymen, 38 

Yagina, 40 

Uterus, 43 

Fallopian  Tubes, 54 

Ovaries, 55 

Bladder  and  Urethra, 56 

Perineum, 58 

Levator  Ani, 58 

Triangular  Ligament, 59 

Sphincter  Yagina, 59 

Sphincter  Ani, 59 

Transversus  Perinei, 60 

Pelvic  Fascia, 60 

Ligaments  of  the  Uterus, 61 

Broad  Ligaments, 61 

Bound.  Ligaments, 62 

Structures  which  support  the  Uterus, 62 

fv) 


VI  C  0  X  T  E  X  T  S . 

CHAPTEE   II. 
PATHOLOGY  AND  DIAGNOSIS. 

PAGE 

Preliminary  Observations, Co 

Pathology  of  Uterine  Disease, 6.J 

Primary  Disease, 63 

Secondary  Disease, •     .     .  64 

Symptoms, 64 

General  Symptoms, 65 

Physical  Signs, 66 

Supra-pubic  Examination, 66 

Examination  per  Vaginam  by  the  touch,      ..."....  67 

Examination  per  Eectum, •     .  60 

Examination  by  the  Speculum, 70 

Examination  with  the  Uterine  Sound, .  72 

Dilatation  of  the  Os  Uteri, 77 

Examination  of  the  Discharges, 77 


CHAPTER  III. 

DISEASES  OP  THE  EXTERNAL  ORGANS  OP  GENERATION. 

Superficial  Inflammation  of  the  Vulva, 79 

Appearances, 79 

Causes, 79 

Treatment, 79 

Phlegmonous  Inflammation  of  the  Vulva,  .  .  .  .  .  .  .  80 

Causes, 80 

Diagnosis, 80 

Treatment, 81 

(Edema  of  the  Labia, 82 

Cohesion  of  the  Labia, 82 

Treatment, 82 

Inflammatory  (Edema, 83 

Encysted  Tumors  of  the  Labia, 83 

Diagnosis, 84 

Treatment, .84 

Oozing  Tumor  of  the  Labia, .85 

Treatment, 85 


CONTENTS.  V]l 

PAGE 

Variccs  of  the  Labi  a, SO 

Causes, .87 

Treatment, 87 

Thrombus,  or  Sanguineous  Tumor  of  the  Labia,  ....  88 

Diagnosis, 89 

Treatment, 89 

Venous   Hemorrhage  from  the  Vulva, 90 

Warty  Tumors  of  the  Vulva, 92 

Symptoms, 92 

Causes,  92 

Treatment, 92 

Vulvar  Enterocele, 93 

Treat7iicnt, 93 

Vaginal  Enterocele, 94 

Pruritus  of  the  Vulva, 94 

Symptoms, 94 

Treatment, 95 


CHAPTEE  IV. 

DISEASES  OF  THE  URETHRA. 

Introduction  of  the  Catheter, 96 

Urethritis, 98 

Symptoms, 98 

Treatment, 99 

Stricture  of  the  Urethra, 102 

Treatment, 102 

Occlusion  of  the  Urethra, 103 

Treatment, 103 

Vascular  Tumor  of  the  Meatus  Urinariiis, 104 

Symptoms, 104 

Treatment, 104 

Foreign  Bodies  in  the  Urethra. 10(1 

Urinary  Calculi, 107 


CHAPTEK    V. 

DISEASES  OF  THE  VAGINA. 
Occlusion  of  the  Vagina, 10 


Vlll  CONTENTS. 

PAGB 

Imperforate  Hymen, 109 

Treatment, 110 

Acquired  Occlusion, Ill 

Treatment, Ill 

Stricture  of  the  Vagina, 113 

Treatment, 114 

Acute  Yaginitis,  . 115 

Causes,  116 

Diagnosis,  110 

Treatment, 117 

Chronic  Yaginitis — Yaginal  Leucorrhea, 118 

Symptoms, 118 

Diagnosis,  119 

Causes,  119 

Treatment, 120 

Prolapse  of  the  Yagina, 122 

Yaginal  Cystocele, * 123 

Symptoms, 123 

Diagnosis,  124 

Treatment, 124 

Yaginal  Rectocele,  , 128 

Causes, 129 

Symptoms, 129 

Diagnosis,  130 

Treatment, 130 

Prolapse  of  the  entire  circumference  of  the  Yagina,  .  .  .  131 

Symptoms, 131 

Diagnosis,  132 

Treatment, 132 

Tumors,  Morbid  Growths,  etc.,  133 

Diagnosis,  133 

Cancer  of  the  Yagina, ..  .  .  .  134 

Diagnosis,  135 

Prognosis,  135 

Treatment, 136 

Vesico-Yaginal  Fistula, 137 

Causes, 137 

Diagnosis,  138 

Treatment, 139 

Palliative  Method, •  ...  140 


CONTEXTS.  IX 

PAGE 

Desault's  Method,         140 

Cauterization,  141 

Suture,         143 

Special    Instruments    for    the    Approximation    of   the 

Edges  of  the  Fistula, 147 

Anaplasty, 147 

Recto-Vaginal  Fistula, 149 

Treatment, 150 

Case  of  Prof.  Freeman's, 151 

Laceration  of  the  Vagina, 154 


CHAPTER  VI. 

Laceration,  or  Rupture  of  the  Perineum, 156 

History, 15(3 

Causes,  156 

Means  of  Prevention, 158 

Consequences  of  Ruptured  Perineum, 159 

Treatment, 159 

Operation  of  Mr.  Baker  Brown, 161 

Centra-Indications  to  Operating, 161 

Time  of  Operating, 162 

Instruments  Required, 162 

Mode  of  Operating, 163 

Division  of  the  Sphincter  Ani, 164 

Insertion  of  the  Quill  Sutures, 164 

Insertion  of  Interrupted  Sutures, 165 

Operation  in  Recent  Cases, 166 

After  Treatment, 166 


CHAPTER  VII. 

Pelvic  Cellulitis, 168 

History, 168 

Causes,       168 

Terminations,      .......          169 

Duration,         170 

Symptoms, 170 


CONTENTS. 

PAOB 

Diagnosis,        , 171 

Treatment, 171 

Fistulous  Passages  remaining  after,  173 

Cases  of, 173 


CHAPTEE  VIII. 

VENEREAL  DISEASES. 

Classification, ...  177 

Gonorrhea, 177 

Different  Varieties  of  Gonorrhea, 178 

Symptoms, 178 

Diagnosis,             ...  182 

Treatment, 182 

Syphilis, 186 

Stages  of,         188 

Inoculation,          189 

Simple  Chancre, ,          .     .  190 

Indurated,  or  Hunterian  Chancre,        190 

Phagedenic  Chancre,        191 

Secondary  Symptoms, 192 

Syphilitic  Vegetations, 197 

Mucous  Tubercles,        198 

Diagnosis,        198 

Treatment  of  Primary  Syphilis, 200 

Treatment  of  Secondary  Syphilis, 203 


CHAPTEE  IX. 
DISEASES  OF  THE  UTERUS. 

Classification, 206 

Occlusion  of  the  Os  Uteri, 207 

Symptoms, 207 

Diagnosis, ...  208 

Treatment, 208 

Congestion  of  the  Cervix  Uteri, 209 

Symptoms, 209 

Causes, 210 

Treatment, 210" 


CONTENTS.  XI 

PA  OH 

Inflammation  of  the  Cervix  Uteri, 211 

Causes,  212 

Symptoms, 214 

Treatment, 21S 

Results  of  Inflammation  of  the  Cervix  Uteri,  ....  223 

Hypertrophy  of  the  Cervix, 225 

Causes, 225 

Symptoms — Treatment, 22<i 

Erosion  of  the  Cervix, 230 

Symptoms — Treatment, 232 

Elevations  the  result  of  Inflammation 232 

Treatment, 234 

Ulceration  of  the  Cervix, 234 

Symptoms — Treatment, 23G 

Corroding  Ulcer  of  the  Uterus, 240 

Pathology, • 240 

Symptoms, 241 

Diagnosis — Treatment, 242 

Cauliflower  Excrescence, 243 

Pathology, 244 

Symptoms, 240 

Diagnosis — Prognosis, 247 

Treatment, 248 

Excision  of  the  Cervix  Uteri, 248 

Cancer  of  the  Uterus, '249 

Pathology, 250 

Symptoms, 252 

Diagnosis,  255 

Prognosis — Treatment, 257 

Metritis, 2G2 

Acute  Metritis, 262 

Causes — Symptoms, 263 

Treatment, 264 

Chronic  Metritis, 266 

Causes  —  Symptoms, 266 

Treatment, 268 

Internal  Metritis — Uterine  Catarrh — Uterine  Leucorrhea,  .  270 

Pathological  Anatomy,  . 270 

Causes  —  Symptoms, 272 

Terminations, 274 


Xll  CONTEXTS. 

PAGE 

Treatment, 275 

Physometra, 279 

Symptoms — Diagnosis, 281 

Treatment,. 282 

Hydrometra, 282 

Varieties, 282 

Causes  —  Symptoms, 283 

Diagnosis,  284 

Treatment, 285 

Moles— Hydatids, 286 

Blighted  or  False  Conception, 286 

Fleshy  Mole, 287 

Hydatids,  or  Vesicular  Mole, 288 

Symptoms, 289 

Diagnosis — Treatment, 290 

Fibroid  Tumors, 291 

Pathological  Anatomy, 291 

Metamorphoses  and  Diseases  of, 296 

Symptoms  of  non-pediculated  Fibroid  Tumors, ....  300 

Diagnosis,  302 

Treatment, 303 

Symptoms  of  Pediculated  Fibroid  Tumors,  or  Polypi,  .  305 

Diagnosis, 310 

Prognosis — Treatment — By  Ligation, 312 

By  the  Ecraseur, 315 

By  Torsion — By  Excision, 318 

By  the  use  of  Caustics, 320 


CHAPTEK  X. 

Hysteralgia  or  Neuralgia  of  the  Uterus, 321 

Symptoms, 321 

Irritable  Uterus, 322 

Diagnosis, '323 

Treatment, 324 

Kheumatism  of  the  Uterus, 326 

Causes  —  Symptoms, 327 

Influence  on  the  Progress  of  Pregnancy, 329 

Influence  on  Labor, 330 

Diagnosis — Treatment, 331 


CO  X  T  KXTS.  XI 11 


CIIAPTEK   XL 

PAOE 

Displacements  of  the  Uterus, 333 

Classification, 333 

Prolapse  of  the  Uterus, 334 

Causes, 334 

Symptoms, 331) 

Diagnosis, 340 

Treatment, 341 

By  Eest  in  the  horizontal  position, 341 

By  Astringent  Injections, 341 

Pessaries, 343 

Rational  method, 346 

Galvanism, 348 

Perineal  Supporter, 349 

Episcraphia, 350 

Eetroversion  and  Retroflexion  of  the  Uterus, 350 

Causes  —  Symptoms, 352 

Diagnosis, 355 

Treatment, 356 

Anteversion  of  the  Uterus, 362 

Causes, 363 

Symptoms — Diagnosis, 364 

Treatment, 365 

Inversion  of  the  Uterus, 365 

Causes, 366 

Symptoms, 368 

Diagnosis — Treatment, 369 


CHAPTER  XII. 

Diseases  of  the  Fallopian  Tubes  and  Ovaries, 372 

Inflammation  of  the  Fallopian  Tubes, 373 

Inflammation  of  the  Ovaries, 374 

Causes  —  Symptoms,      .         374 

Terminations, 375 

Diagnosis — Treatment, 376 

Ovarian  Dropsy, 377 

Pathology, 378 


XIV  CONTEXTS. 

PAGE 

Simple  Cj-sts, 378 

Multilocular  or  Proliferous  Cysts, 379 

Structure, 380 

Contents  —  Symptoms, 382 

Diagnosis, 383 

Treatment, 385 

B}T  Compression  and  Palpation, 385 

By  Tapping, 3SG 

By  Tapping  with  Pressure, 388 

By  Tapping  and  Injeetion  of  Iodine, 388 

By  Artificial  Oviduct, 389 

Excision  of  a  portion  of  the  Cyst, 391 

•  Extirpation,  or  Ovariotomy, 392 

Ecasons  for  and  against,        392 

Conditions  rendering  Ovariotomy  justifiable,       ....  395 

Preparations  for  the  Operation, 395 

Mode  of  operating, 396 

Dangers  to  be  apprehended  after  Ovariotomy,    ....  399 

Tumors  of  the  Ovary, 401 

Fibroid  Tumors  of  the  Ovary, 401 

Cancer  of  the  Ovary, 401 

Sj'mptoms, 402 

Diagnosis — Treatment, 403 


CHAPTEE  XIII. 

Puerperal  Fever, 404 

Causes, 404 

Pathological  Anatomy, 407 

Puerperal  Endometritis, 409 

Inflammation  of  the  Veins  and  Lymphatics  of  the  Uterus,  410 

Inflammation  of  the  Peritoneum, 412 

Puerperal  Ovaritis, 413 

Summary  of  the  Anomalies  in  other  organs,  accompany- 
ing the  above-described  processes, 414 

Secondary  terminations,        420 

Symptoms — Symptoms  in  the  Inflammatory  form,     .     .  421 

Symptoms  in  the  Typhoid  form, 423 

Diagnosis,        426 

Prognosis — Treatment, 428 


CONTENTS.  XV 


Phlegmasia  Dolens, 435 

Pathology  of, 436 

Symptoms, 437 

Diagnosis — Treatment, 439 


CHAPTEK   XI V. 

Functional  Diseases, 441 

Classification, 441 

Leucorrhea, 442 

Amenorvhea, 444 

Emansio  Mensium,  or  Absent  Menstruation, 444 

Symptoms, 446 

Causes — Treatment, 447 

Suppressio  Mensium,  or  Suppressed  Menstruation,      .     .  448 

Symptoms, 448 

Diagnosis, 449 

Treatment, 450 

Dysmenorrhea, 453 

Neuralgic  Dysmenorrhea, 453 

Symptoms  —  Causes, 454 

Treatment. 455 

Inflammatory  Dysmenorrhea — Diagnosis, 457 

Treatment, 458 

Mechanical  Dysmenorrhea, 458 

Treatment, 459 

Menorrhagia, 459 

Menorrhagia,  with  the  discharge  of  the  Normal  Men- 
strual Fluid — Symptoms,      .          460 

Causes — Treatment, 461 

Menorrhagia,  with  the  Discharge  of  Blood  directly  from 

the  Uterine  Vessels, 462 

Symptoms, 462 

Causes — Diagnosis — Treatment, 465 

Chlorosis, 467 

Pathology, 468 

Causes, 470 

Symptoms, 471 

Treatment, 472 


XVI  CONTENTS. 

PAGl 

Hysteria, , 477 

Pathology, 477 

Symptoms, 478 

Diagnosis — Causes — Treatment, 480 


CHAPTER  XV. 
DISEASES  OF  THE  BREASTS. 

Introductory  Remarks, 483 

Classification  of  Diseases, 484 

Anatomy  of  the  Breasts, 484 

Pathology, 492 

Diseases  before  Puberty, 494 

Milk-like  Secretion  from  the  Mammary  Gland  of  the  Infant,    494 

Inflammation  of, 495 

Inflammation  of,  following  Hemorrhage  from  the  Vulva,  .     .  495 

Malignant  disease  near  the  age  of  Puberty, 496 

Effects  of  Simple  Inflammation, 498 

Treatment, 498 

Mammary  Abscess, 501 

Chronic  Abscess, •     .  502 

Lactiferous  Swelling, 503 

Cellulose  Hydatids, 503 

Chronic  Mammary  Tumor, 506 

Irritable  Tumor, 507 

Carcinoma,  or  Cancer  of  the  Breast, 5C8 

Pathology  of, 510 

Treatment  of, 514 


INTRODUCTION. 


The  first  questions  that  require  study  are,  why  is  disease  of  the 
reproductive  organs  of  women  so  common,  and  why  are  they  so 
difficult  of  cure?  I  answer  the  first  by  saying  that  they  are  com- 
mon because  the  reproductive  organs  are  not  properly  cared  for, 
and  nre  subject  to  continuous  abuse.  They  are  difficult  of  cure  for 
the  same  reasons,  and  because  the  physician  will  not  see  the  neces- 
sity of  rest  and  a  restorative  treatment.  The  reader  may  think 
these  claims  are  broad,  but  we  hope  to  be  able  to  substantiate  them, 
and  in  doing  so,  point  out  the  way  for  a  better  treatment. 

The  law  of  development  reads,  "  as  a  part  is  rightty  used,  it  gets 
increased  development  and  strength."  The  reproductive  appara- 
ratus  is  intimately  associated  in  its  development  with  the  condition 
of  the  lower  portion  of  the  body — with  the  apparatus  of  locomo- 
tion. Show  me  the  Avoman  who  has  well  developed  legs,  and  the 
capacity  for  active  and  continued  movement,  and  I  will  show  you 
one  who  has  a  well  developed  and  strong  reproductive  apparatus. 
If  this  is  the  fact,  we  see  the  importance  of  active  out-door  exer- 
cise in  gii-lhood — leg  exercise;  and  the  importance  of  Avell  regu- 
lated exercise  in  the  adult.  If  a  feeble  woman  is  about  to  enter 
the  married  state,  and  call  into  use  this  apparatus,  there  is  especial 
reason  why  a  well  regulated  exercise  for  pelvic  development  should 
be  adopted.  If,  now,  exercise  in  the  open  air  is  commenced,  and 
gradually  increased  from  day  to  day,  we  will  find  a  most  marked 
improvement  in  the  tone  of  the  pelvic  structures  in  the  course  of 
a  few  months. 

Inattention  to  the  bowels  and  bladder  is  a  very  common  cause 
of  uterine  disease.  The  girl  or  woman  has  so  much  occupation, 
or  knows  so  little  of  the  importance  of  these  functions,  that  she 
neglects  them,  becomes  irregular,  and  must  suffer  physical  lesions 
of  the  pelvic  viscera  in  consequence.  No  woman  who  neglects 


18  INTRODUCTION. 

these  important  functions  can  have  perfect  health,  and  Very  many 
will  grow  some  disease  in  this  way. 

Want  of  rest,  and  exposure  during  the  menstrual  period,  is  a 
frequent  source  of  disease,  and  it  is  well  to  impress  upon  the  minds 
of  our  women  the  need  of  care  at  these  times.  Not  but  that  a 
woman  who  had  inherited  a  vigorous  body,  and  had  lived  an  ac- 
tive, healthy  life,  might  not  endure  very  great  exposure  without 
suffering, 

Congenital  hydrophobia  is  a  very  common  cause  of  uterine  dis- 
ease. Some  women  never  wash — anything  but  their  faces — and 
have  to  be  taught  that  in  civilized  life  cold  water  may  compensate 
for  sedentary  habits.  The  woman  of  lax  fibre  and  feeble  develop- 
ment will  find  the  vigorous  application  to  the  pelvis,  abdomen, 
and  genitalia,  of  cold  water,  with  brisk  friction  in  drj'ing,  a  most 
important  means  of  development. 

I  am  free  to  say,  that  no  woman  has  a  right  to  enter  the  marital 
relation,  unless  she  can  perform  the  duties  appertaining  to  it.  If 
the  body  is  feeble,  or  lacks  development,  her  duty  to  herself,  her 
husband,  her  children,  and  to  society,  demands  that  she  employ 
all  means  to  recover  physical  and  sexual  health.  I  leave  it  to  the 
reader  to  say,  from  his  experience,  if  these  are  not  facts ;  if  they 
are,  the  physician's  duty  in  the  premises  is  very  clear — -educate 
the  people  to  right  views  of  life. 

With  the  use  of  the  reproductive  apparatus  comes  abuse,  and 
from  this  many  cases  of  uterine  disease  are  grown.  In  early  mar- 
ried life  comes  too  frequent  copulation,  and  excessive  excitement 
of  the  reproductive  apparatus,  sometimes  without  the  relief  that 
comes  from  the  completed  venereal  orgasm.  Then  pregnancy 
follows  without  a  knowledge  of  the  care  that  should  be  used  in 
this  condition,  and  frequently  a  too  early  return  to  the  exhausting 
labors  of  the  household  after  childbirth.  Then  possibly  exhaust- 
ive and  prolonged  lactation  comes  in  to  complete  the  wrong  to  the 
previously  exhausted  reproductive  apparatus.  In  many  cases  the 
cares  of  life  are  so  great  as  to  exhaust  the  vital  forces  ;  in  other 
cases  the  labor  in  the  care  of  the  household  is  exhaustive,  and  in 
others  the  food  is  so  imperfectly  prepared  that  the  woman  can  not 
make  blood  enough  to  sustain  healthy  life. 

In  thus  naming  the  common  causes  of  the  diseases  we  meet  in 
women,  the  physician  may  see  how  they  can  be  avoided,  and  he 


INTRODUCTION.  19 

certainly  will  see  the  necessity  of  rectifying  these  wrongs,  if  he  is 
to  have  success  in  the  use  of  remedies.  It  not  only  suggests  the 
good  that  may  come  from  popular  education  in  these  matters,  to 
prevent  female  diseases,  but  the  necessity  of  avoiding  them,  if  per- 
manent cures  are  to  be  effected. 

If  we  think  for  a  moment  of  the  acute  diseases  of  women,  we 
will  see  that  they  do  not  differ  materially  from  diseases  of  the 
other  sex,  and  if  we  select  remedies  according  to  special  expres- 
sions of  disease  (general  principles?),  we  have  excellent  success. 
As  with  other  organs  or  parts,  we  find  there  are  remedies  which 
have  a  special  action  upon  the  uterus  and  ovaries,  and  this  chiss  is 
frequently  brought  into  requisition.  But  it  will  not  do  to  forget, 
in  using  them,  the  large  classes  that  influence  the  appetite,  diges- 
tion, blood-making,  the  circulation  of  the  blood,  the  nutrition  of 
tissue,  its  waste,  and  its  excretion,  with  the  general  and  local  tem- 
perature and  in  nervation. 

If,  for  instance,  I  am  called  to  treat  a  case  of  acute  ovaritis  or 
metritis,  what  remedies  shall  I  employ?  Adopting  the  physio- 
logical plan,  I  will  select  the  proper  sedative,  the  proper  bath,  the 
local  application,  means  to  establish  secretion  from  the  skin,  kid- 
neys and  bowels,  and  to  give  right  innervation.  What  more  will 
I  do?  If  there  is  or  has  been  a  wrong  of  the  menstrual  function, 
I  use  the  special  remedy  indicated  after  the  treatment  first  named. 
Or  if  there  has  been,  or  is,  or  will  be,  abuse  of  the  reproductive 
function,  I  give  the  advice  necessary.  Have  I  to  do  very  much 
more  than  if  it  was  a  case  of  inflammation  of  the  lun^s? 

O 

Let  us  have  an  example  in  a  recent  case.  Mrs.  H.  has  recently 
returned  from  a  long  journey,  and  the  fatigue,  and  the  frequent 
change  of  temperature  in  the  cars,  produced  irritation  and  deter- 
mination of  blood  to  the  pelvic  viscera,  increased  by  its  being 
about  the  time  of  the  menstrual  period.  The  discharge  made  its 
appearance  for  a  few  hours,  and  then  ceased,  followed  by  high 
fever  and  evidence  of  inflammatory  action.  Pulse  120,  full;  tem- 
perature 105  ;  tongue  somewhat  full,  and  covered  with  a  yellowish 
fur  ;  severe  pain  in  the  pelvic  region,  and  exquisite  tenderness  on 
pressure.  There  was  much  irritation  of  the  nervous  system,  and 
a  scanty  urine  passed  with  difficulty. 

Prescribed — R  Tinct.  Veratrum,  gtt.  x.;  Tinct.  Gelseminum,  gtt. 
xx.;  water,  3iv.;  a  teaspoonful  every  hour.  Bowels  moved  with 


20  INTRODUCTION. 

an  enema  of  tepid  water.  The  next  morning  there  was  a  decided 
improvement,  and  substituted — R  Tinct.  Yeratrum,  gtt.  v.;  Tinct. 
Macrotj-s,  gtt.  x.;  water,  3iv.;  a  teaspoonful  every  hour.  Pretty 
comfortable  the  next  day;  pain  gone,  but  little  tenderness;  com- 
plained of  some  dullness  and  unpleasant  sensations  in  the  ears. 
Continued  the  medicine  every  three  hours,  and  ordered  a  single 
grain  of  quinine  at  10  A.  M.  The  menstrual  discharge  came  on 
that  night,  and  convalescence  was  rapid  and  good. 

I  give  this  case  to  show  the  similarity  of  the  treatment  to  that 
of  other  diseases.  But  one  special  remedy  \vas  employed,  Macro- 
tys,  and  even  that  would  have  been  quite  as  useful  in  an  inflamma- 
tion of  the  lungs,  if  there  had  been  the  same  tensive,  wave-like 
pain. 

Now  let  us  have  two  cases,  male  and  female,  as  an  example. 
Miss  T.  follows  the  occupation  for  which  Solomon  was  so  famous, 
("  But  King  Solomon  loved  many  strange  women,")  and  suffered 
severely  at  times  with  ovarian  neuralgia,  and  slight  inflammation. 
I  had  treated  her  several  times,  but  the  influence  of  medicine  was 
not  satisfactory.  Finally  I  was  called  when,  with  the  ovarian 
trouble,  was  a  sore  throat  with  the  peculiar  aching  indicating  Phy- 
tolacca.  I  prescribed  it  in  the  usual  dose — R  Tinct.  Pli3Ttolacca, 
gtt.  x.;  water,  siv.;  a  teaspoonful  every  two  hours.  The  result — 
she  was  wholly  free  from  pain  in  twelve  hours.  It  has  been  re- 
peated once  since  with  the  same  result.  S.  R.  has  neuralgia  of  the 
testes  from  the  same  cause,  which  has  troubled  him  for  months. 
The  scrotum  is  pendulous,  the  testes  full,  and  tender  on  pressure, 
and  the  dragging  pain  is  sometimes  almost  insupportable.  Pre- 
scribed— R  Tinct.  Phytolacca,  gtt.  x.;  water,  3iv.;  a  teaspoonful 
every  three  hours  ;  no  support.  There  was  speedy  relief,  and  no 
recurrence  of  the  trouble  after  taking  the  second  bottle.  I  have 
an  object  in  giving  these  cases,  that  will  appear  further  along,  but 
the  reader  can  draw  his  own  conclusions  now. 

1  think  the  majority  will  agree  with  me  that  a  right  treatment 
of  acute  diseases  of  the  reproductive  organs  of  a  woman  must  be 
based  upon  right  general  principles,  and  that  it  should  be  such  a 
treatment  as  would  cure  a  similar  disease  of  any  other  part,  plus 
the  remedy  or  remedies  that  exert  a  special  influence  upon  these 
tissues.  Agreeing  upon  this,  can  we  not  agree  that  a  right  treat- 
ment of  chronic  diseases  of  the  reproductive  organs  of  women 


INTRODUCTION.  21 

should  be  such  a  treatment  as  would  cure  a  similar  disease  of  any 
other  part,  plus  the  remedies  that  influence  specialty  these  tissues, 
or  this  function  ?  This  conceded  and  we  are  then  able  to  do  our 
thinking  in  straight  lines, 

In  the  cure  of  a  chronic  disease,  functional  or  structural,  what 
is  the  first  condition?  To  get  as  good  a  condition  of  the  general 
health  as  possible.  What  is  the  second  condition  ?  To  give  the 
organ  or  part  rest.  Let  us  apply  this  to  the  cases  in  hand.  The 
Avoman  requires  the  common  conditions  of  healthy  life,  sunlight, 
good  air.  good  food,  and  reasonable  exercise.  In  order  to  have 

O  '    O  ' 

good  tissue  and  a  healthy  body,  she  needs  good  digestion  and 
blood-making,  a  good  circulation,  tissues  called  into  use,  good 
waste,  excretion,  temperature,  and  innervation.  Will  any  special 
remedy  compensate  for  these?  Is  the  local  use  of  the  speculum, 
and  the  instrument  bag  and  medicine  chest  of  the  gynaecologist, 
compensation  ? 

Let  us  think  for  a  moment  of  rest  as  a  means  of  cure.  Eecall 
the  cases  of  uterine  disease  that  have  come  under  your  notice,  and 
see  in  how  many  of  these  exhaustive  household  labor  has  been  a 
prominent  cause;  in  how  many  too  rapid  childbearing  has  been  a 
cause  ;  in  how  many  prolonged  lactation  has  been  a  cause  ;  in  how 
many  mental  troubles  and  worry  has  been  a  cause;  and  in  how 
many  marital  excesses  (not  the  fault  of  the  woman)  has  been  a 
cause.  When  I  have  taken  these  cases  out,  I  find  but  few  left.  It 
is  true  that  many  girls  are  not  properly  raised,  and  have  not  a 
right  development  for  the  mothers  of  families,  but  these  give  but 
few  cases,  if  the  abuses  named  above  are  not  added.  These  are 
not  only  causes  producing  the  common  diseases  of  women,  but 
they  are  present  causes  continuing  disease. 

One  of  the  first  lessons  we  learn  in  the  practice  of  medicine  is, 
that  present  causes  of  disease  must  be  removed.  In  the  treatment 
of  chronic  disease  this  is  essential,  and  we  do  not  expect  success 
unless  we  look  closely  to  this.  Now  let  us  reason  together.  If  a 
woman  suffering  from  uterine  disease  is  overburdened  with  house- 
hold cares,  what  needs  be  done  to  insure  a  cure  ?  If  a  woman  is 
bearing  children  so  rapidly  as  to  exhaust  her  life,  what  needs  be 
done  to  insure  a  return  to  health  ?  If  a  woman's  life  is  exhausted 
by  lactation,  what  needs  be  done  ?  If  a  woman's  life  is  exhausted 


22  INTRODUCTION. 

and  the  reproductive  organs  diseased  by  marital  abuse,  what  needs 
be  done  ? 

"We  want  a  clear  and  intelligible  understanding  of  these  matters 
at  the  commencement,  and  I  claim  that  no  one  can  have  success 
who  fails  to  regard  them.  I  will  not  concede  that  it  is  impossible 
to  correct  these  wrongs  of  life  in  the  larger  number  of  cases,  even 
among  the  poor,  or  the  hard  worked  women  on  the  farms  of  the 
frontiers.  If  the  physician  makes  the  suggestions  in  a  kindly 
manner,  and  gives  a  sufficient  reason  for  the  proposed  changes  in 
the  methods  of  life,  means  will  be  found  to  accomplish  the  object. 

Standing  next  to  good  food  well  prepared,  we  rank  water  as  a 
curative  agent.  As  a  means  for  retaining  health,  it  can  not  be 
overestimated.  As  a  rule,  the  woman  who  habitually  uses  a  sponge 
bath  of  cold  water  to  the  pelvic  region  will  remain  healthy.  I 
have  had  occasion  to  recommend  it  in  several  cases  to  pregnant 
women,  as  a  means  of  avoiding  the  many  unpleasant  symptoms 
they  suffered  from  during  the  last  months  of  gestation,  and  after 
childbirth,  and  it  has  proven  so  uniformly  satisfactory,  that  it  has 
been  continued  afterward.  There  is  no  mistake  but  that  the  use 
of  cold  water,  followed  by  brisk  friction  in  drying,  increases  the 
strength  of  the  circulation,  the  innervation  and  the  nutrition  of 
parts.  Among  the  advantages  following  the  use  of  cold  water  is 
the  less  liability  to  take  cold.  Let  it  be  recollected  that  the  feeble 
part  always  suffers  in  the  wrong  of  the  circulation  we  call  "cold." 
If  we  have  an  enlarged  or  ulcerated  cervix,  a  leucorrhoea,  or  a  dis- 
placement of  the  uterus,  it  grows  worse  at  every  exposure  or 
change  of  temperature,  and  we  lose  as  much  at  these  times  as  we 
have  gained  between  them.  Let  me  report  a  case  as  an  example 
of  the  use  of  cold  water. 

Mrs.  M is  a  chronic  sufferer  from  uterine  disease,  and  has 

been  the  rounds  of  g4ynaecologi8ts,  but  without  permanent  benefit. 
Her  back  is  so  weak  and  painful  that  she  is  not  able  to  take  exer- 
cise. Examination  shows  an  enlarged  uterus,  cervix  full  and 
doughy,  os  open,  and  abundant  cervical  discharge,  a  large  ulcer  of 
the  os  extending  to  the  cervical  canal,  with  prolapsus  to  the  extent 
that  at  the  menstrual  periods  the  os  would  come  to  the  vulva.  At 
the  menstrual  period  there  was  marked  congestion  of  the  pelvic 
viscera,  relieved  after  a  time  by  profuse  menstruation.  The  treat- 
ment was  commenced  with  the  cold  water  sponge  bath,  the  patient 


INTRODUCTION.  23 

lying  between  blankets,  which  were  used  to  dry  the  surface.  It 
would  be  applied  briskly  to  the  spine  its  entire  length,  then  thor- 
oughly dried  by  friction  through  the  blanket ;  then  the  water 
would  be  applied  to  the  abdomen,  with  the  same  thorough  rubbing ; 
then  to  the  perineum  and  vulva,  and  then  to  the  hips  and  upper 
part  of  the  thighs.  She  was  instructed  to  keep  the  vagina  and 
vulva  free  from  the  discharges  by  washing  in  water.  A  perineal 
supporter  was  employed  to  sustain  the  pelvic  organs  when  on  her 
feet,  and  moderate  exercise  was  taken  daily  in  the  open  air.  There 
was  a  decided  improvement,  and  with  change  of  scene  and  pleas- 
ant company,  there  was  an  entire  restoration  of  the  health.  No 
medicines  were  used,  and  a  case  of  some  eight  years'  standing  was 
cured  with  cold  water,  brisk  frictions,  and  the  perineal  supporter, 

Let  me  call  attention  to  the  well  adjusted  abdominal  bandage 
and  perineal  supporter  as  a  means  for  giving  rest  to  the  debilitated 
tissues  closing  the  outlet  of  the  pelvis.  Rest  is  absolutely  essen- 
tial to  success,  and  yet  if  these  tissues  are  forced  to  support  the 
organs,  they  are  overworked  every  day.  This  temporaiy  support 
gives  rest  until  by  increased  nutrition  we  have  grown  tissues  strong 
enough  to  give  support. 

Let  me  call  attention  to  the  advantage  of  passive  movements  in 
the  treatment  of  all  affections  that  show  debility  and  relaxation 
of  tissues.  For  twenty  years  I  have  employed  the  Swedish  move- 
ment cure  in  these  cases,  and  with  most  flattering  results.  The 
treatment  is  usually  a  combination  of  means  to  give  rest,  i.  e.,  to 
lessen  household  labor  on  the  feet,  and  the  perineal  supporter  to 
support  the  structures,  and  passive  movement  to  stimulate  a  better 
innervation  and  circulation.  The  employment  of  electricity  takes 
the  place  of  this  "movement  cui-e,"  and  when  judiciously  employed 
gives  most  satisfactory  results. 

1, Let  us  see  what  we  have  thus  far.     Good  food,  well   prepared. 

Fresh  air  and  sunshine.  Moderate  exercise,  that  is  not  work. 
Relief  from  care,  worry,  and  exhaustive  labor.  The  stimulus  of 
cold,  the  cleanliness  of  water,  and  the  invigoration  of  frictions. 
Cold  water  as  a  means  of  preventing  colds.  Rest  by  proper  out- 
side support,  and  stimulus  to  nutrition  by  the  "movement  cure." 
Now  add  good  clothing,  freedom  from  exhaustive  discharges,  a 
fight  use  of  the  reproductive  apparatus,  and  we  have  the  basis  for 
a  successful  practice. 


24  INTRODUCTION. 

There  is  a  general  treatment  for  many  of  these  cases  that  must 
not  be  neglected,  but  it  is  not  one  that  can  be  formulated  in  a  R. 
No  "  compound  syrup,"  thank  you.  No  "  restorative  bitters,"  if 
you  please.  No  "  uterine  renovator,"  if  our  ears  are  level.  If 
the  tissues  of  the  body  are  not  well  made,  it  will  be  necessary  to 
make  them  over.  How  ?  you  ask.  By  the  methods  named  in 
-Chambers' Eenewal  of  Life.  We  see  that  the  excretory  organs 
are  active,  and  the  processes  of  retrograde  metamorphosis  go  on 
well,  that  the  old  body  may  be  carried  out.  Then  we  use  such 
means  as  may  be  necessary  to  give  good  digestion,  blood-making, 
a  good  circulation  and  innervation,  that  a  new  and  better  body 
may  be  built  in  its  place.  Here  we  have  an  old  and  diseased  ute- 
rus, diseased  because  it  is  old,  and  disease  irreparable  unless  we 
can  get  a  better  organ.  You  ask,  how  an  "  old  uterus  "  in  a  young 
woman?  Easy  enough — a  tissue  has  a  life  of  about  four  months, 
and  is  continuously  being  born  again.  If  the  life  of  the  tissue  is 
prolonged  beyond  four  months,  and  it  is  not  reborn  frequently 
enough,  it  becomes  old.  What  shall  we  do  ?  Stimulate  the  gene- 
ral processes  of  waste  and  nutrition,  and  renew  the  entire  body  to 
newness  of  life,  uterus  and  all. 

Again,  my  experience  in  the  use  of  special  remedies  has  proven 
to  me  that  when  special  symptoms  calling  for  a  remedy  are  prom- 
inent, it  will  cure  uterine  as  well  as  any  other  disease.  Let  me 
give  a  couple  of  examples  from  the  last  season. 

Mrs.  T.  has  suffered  more  or  less  since  the  birth  of  her  last  child, 
now  over  two  years.  She  complains  of  bearing  down,  fullness  in 
the  pelvis,  a  weak  back,  has  leucorrhcea,  and  her  general  health  is 
impaired.  A  digital  examination  shows  an  enlarged  uterus,  cervix 
hypertrophied,  tissues  inelastic,  organs  low  down  in  the  pelvis. 
Her  face  is  full,  there  is  venous  fullness,  her  tongue  is  full,  inclined 
to  be  dirty ;  she  has  sense  of  dizziness  in  the  head,  pain  in  the 
ischiatic  notches,  and  lumpy  fteces,  followed  by  thin  fasces  and 
mucus.  All  the  indications  for  Podophyllin,  and  I  prescribe — R 
Podophyllin,  gr.  j.;  Phosphate  of  H}7drastia,  gr.  x.;  make  twenty 
pills.  One  to  be  taken  at  mid -afternoon.  Exercise  in  the  open 
air  and  good  food.  You  would  say  that  this  was  scant  treatment, 
and  yet  she  is  sound  and  well,  nothing  else  having  been  employed, 
and  the  prescription  not  renewed.  You  say  it  was  the  exercise  in 


INTRODUCTION.  25 

the  open  air  and  good  food  that  did  it;  so  be  it,  cure  your  cases  in 
the  same  way. 

Mrs.  W.  has  suffered  for  some  months  with  the  usual  symptoms 
of  uterine  disease.  Monthly  periods  irregular,  discharge  scanty 
and  dark  in  color.  Has  been  treated  before  with  escharotics  for 
disease  of  the  cervix  and  ulceration,  and  does  not  want  to  go 
through  the  same  process  again.  Examination  determined  a  cer- 
vix slightly  enlarged,  tissue  dense,  and  a  peculiar  velvety  sensa- 
tion at  points — erosion  ;  near  the  os  a  well  defined  ulcer. 

The  tongue  showed  the  marked  violet  color,  calling  for  nitric 
acid,  which  was  prescribed.  And  without  change  of  medicine  she 
was  relieved  in  a  couple  of  weeks.  Her  health  for  the  past  three 
months  has  been  better  than  for  years. 

The  menstrual  function  plays  an  important,  part  in  the  life  of 
the  woman  from  puberty  to  the  "  change  of  life,"  at  the  age  of  forty 
to  fifty  years.  It  ma}'  be  stated  as  a  truism,  that  health  of  the 
reproductive  organs  is  dependent  upon  a  normal  performance  of 
the  menstrual  function.  It  is  possible  that  there  may  be  normal 
menstruation  with  considerable  disease  of  these  organs,  but  a 
wrong  of  the  menstrual  function  is  sooner  or  later  followed  by 
structural  disease.  So  markedly  is  this  the  case  that  the  estab- 
lishment of  normal  menstruation  is  one  of  the  essentials  of  suc- 
cessful treatment. 

This  brings  us  to  the  consideration  of  those  remedies  that  influ- 
ence the  menstrual  function.  We  may  classify  them  as  agents 
which  promote  the  discharge,  agents  which  diminish  the  discharge, 
and  agents  which  rectify  perversions  of  the  dischat-ge.  If  we 
"were  classif}Ting  the  lesions  of  menstruation,  we  might  group  them 
in  three  classes — arrest,  tardy  in  appearance,  scanty — too  free,  too 
frequent  in  recurrence,  prolonged  in  duration — painful,  changed 
in  character.  Whatever  remedies  are  recommended  for  either  of 
these  lesions,  look  to  a  right  performance  of  function,  and  a  single 
.agent  will  sometimes  relieve  either  of  the  three  lesions. 

Standing  first  in  the  list  of  these  remedies  is  the  Macrotys,  and 
for  these  uses  we  employ  a  tincture  of  the  fresh  or  recently  dried 
root,  the  dose  being  small,  gtt.  v.  to  gtt.  xx.  to  four  ounces  of  water, 
a  teaspoonful  every  one,  two,  three,  or  four  hours.  It  seems  to 
iave  a  direct  action  in  restoring  the  menstrual  dischai'ge,  if  the 
arrest  is  associated  with  undue  vascular  or  nervous  excitement. 


26  INTRODUCTION. 

It  exerts  a  special  influence  upon  the  tissues,  looking  towards  the 
normal  period,  whether  tardy  or  two  frequent,  but  in  the  last  case 
must  be  employed  in  very  small  doses.  And  it  is  one  of  the  most 
important  remedies  we  have  for  painful  menstruation,  or  wrong 
of  evolution  or  involution  in  pregnancy  and  after  childbirth. 

Having  a  somewhat  similar  action  are  the  remedies  Caulophj'l- 
lum,  and  the  two  species  of  Actsea,  alba  and  rubra.  These  reme- 
dies have  a  marked  action  upon  the  reproductive  apparatus  and 
function,  but  have  not  been  so  thoroughly  studied  as  the  Macrotys. 
I  have  used  the  Caulophyllum  with  marked  advantage  where  there 
was  congestion  with  a  sense  of  fullness  and  weight  in  the  pelvis, 
the  wrong  of  the  menstrual  function  being  associated  with  hys- 
teria. 

Pulsatilla  is  one  of  my  favorite  remedies.  It  is  par  excellence 
the  remedy  for  arrest  of  menstruation,  for  tardy  menses,  and  for 
scanty  menses,  if  there  is  simple  derangement  of  function  without 
local  vascular  or  nervous  excitement.  General  nervousness — the 
lesion  of  the  mind — is  a  prominent  indication.  The  Pulsatilla  is 
also  a  prominent  remed€y  for  painful  menstruation,  if  associated 
with  the  head  symptoms,  and  like  the  preceding  agents  it  looks 
towards  healthy  functional  activity  and  healthy  nutrition. 

In  the  list  of  remedies  favoring  the  menstrual  discharge  may  be 
included  Iron,  not  only  as  a  blood-maker,  or  a  general  remedy, 
but  for  its  local  influence.  Blueness  of  parts,  usually  with  pallor, 
may  be  taken  as  the  best  indication  for  its  specific  action.  Tissues 
are  full,  and  frequently  the  lower  segment  of  the  uterus  will  give 
a  doughy  or  sodden  sensation  to  the  finger.  The  tincture  of  mu- 
riate of  iron — a  specific  in  a  certain  variety  of  erysipelas — will  be 
indicated  by  erysipe'.oid  redness  of  the  surface,  frequently  of  the 
lower  extremities,  and  of  the  external  and  even  of  the  internal 
parts.  One  of  the  most  marked  indications  for  iron  is  constant 
pain  in  the  posterior  part  of  the  head. 

Apocynum  is  a  very  valuable  remedy  in  the  treatment  of  dis- 
eases of  women.  The  indications  are,  fullness  of  abdomen,  ute- 
rus enlarged,  and  tendency  to  oedema  of  the  extremities. 

Graphites  may  be  employed  when  the  monthly  discharge  is  pale 
and  watery,  with  prominent  hysteric  symptoms. 

Polygonum  when  there  is  sensation  of  weight  and  fullness  in 
the  pelvis,  with  aching  in  the  hips. 


INTRODUCTION.  27 

The  Mitchella,  Senecio,  and  Helonias,  find  a  use  here,  but  I  am 
not  able  to  point  out  the  special  indications  for  either. 

Tincture  of  Phosphorus  may  be  thought  of  as  a  remedy  when 
there  is  want  of  innervation,  and  the  reproductive  function  (vene- 
real desire)  is  markedly  impaired. 

Iodine  has  a  similar  use,  and  is  usually  associated  with  .Nux 
(compound  iodine  pill),  to  give  energy  to  the  reproductive  organs. 

"When  we  think  of  the  remedies  for  the  conditions  of  too  free, 
too  frequent  in  recurrence,  and  prolonged,  we  wish  to  make  a 
classification  into  those  for  plus  vascular  and  nervous  excitement — 
active  condition;  and  minus  vascular  and  nervous  excitement — 
passive  condition. 

The  remedies  for  the  first  will  be  found  in  the  class  sedative — 
Aconite,  Yeratrum,  Lobelia,  Bryonia,  Khus,  Lycopus,  Gelseminum, 
Asclepias — and  we  need  not  give  them  an  individual  study  here. 

The  second  group  may  be  headed  with  Carbo-veg.,  which  is  one 
of  our  most  certain  remedies.  The  indications  are,  pallor,  loose- 
ness of  tissues,  and  a  soft,  open  pulse.  It  not  only  regulates  the 
menstrual  discharge,  as  to  quantity,  frequency  of  recurrence,  and 
duration,  but  it  exerts  a  marked  influence  on  the  nutrition  of  these 
tissues.  I  use  a  trituration  one  to  ten,  and  possibby  it  would  be 
better  in  some  cases  to  use  a  second  trituration. 

The  Hamamelis  is  another  very  valuable  remedy,  and  is  indi- 
cated by  fullness  of  pelvic  tissues,  laxit}r  of  perineum,  and  impair- 
ment of  the  venous  circulation.  These  are  the  indications  for  the 
remedy,  whether  there  is  a  wrong  of  the  menstrual  function  or  not. 

Ergot  may  be  employed  when  the  tissues  are  full  and  relaxed, 
and  when  there  is  oppression  of  the  nervous  system,  the  patient 
being  dull,  stupid  and  careless. 

Ipecac  is  a  very  valuable  remedy  when  there  is  local  irritability 
with  lax  tissues,  though  it  may  be  employed  in  any  case  in  which 
irritability  of  mucous  membrane  is  a  marked  feature. 

The  pain  or  uneasiness  associated  with  the  menstrual  discharge, 
and  felt  at  other  times,  is  veiy  variable  in  character  and  intensity. 
There  may  be  nothing  characteristic  about  it,  or  it  may  point  out 
the  remedy  for  us. 

Nux  is  the  remedy  we  usually  think  of  for  uterine  colic.  Do  not 
mistake  the  language — there  is  a  uterine  pain  that  simulates  colic, 
even  to  its  wandering  character  in  the  lower  abdomen  and  pelvis. 


28  INTRODUCTION. 

The  remedy  not  only  relieves  the  pain,  but  greatly  aids  in  estab- 
lishing normal  nutrition  and  functional  activity.  I  saw  a  marked 
case  in  the  early  part  of  1874,  in  which  the  wonan  had  been  a  con- 
stant sufferer  from  uterine  disease  since  1867.  The  character  of 
the  pain  was  so  decided  that  I  gave  her  nothing  but  Xux  at  first, 
and  as  the  results  were  so  satisfactory  no  other  remedy  was  em- 
ployed, and  she  made  a  good  recovery  in  three  months. 

We  do  not  want  to  forget  that  the  Macrotys,  Caulophyllum, 
Actsea  and  Pulsatilla,  are  remedies  for  pain,  and  may  be  indicated 
by  pain,  As  remarked  at  first,  nearly  all  of  these  remedies  look 
toward  normal  function,whatever  may  be  the  indication  for  their  use. 

The  Viburnum  (Opulus)  high  cranberry,  cramp  bark,  is  a  most 
valuable  uterine  remedy,  and  not  only  looks  to  normal  innervation, 
but  to  normal  circulation  and  nutrition  as  well.  It  is  indicated  by 
pain — its  common  name,  cramp  bark,  is  very  suggestive  of  the  kind 
of  pain — uterine  spasm.  The  Viburnum  (Prunifolium),  black  haw, 
exerts  a  very  similar  action,  and  is  also  indicated  by  pain — expul- 
sive and  intermittent.  Both  are  remedies  for  abortion,  and  espe- 
cially to  remove  the  predisposition  to  it.  The  reader  will  recall 
cases  in  which  there  is  a  continued  tendency  to  abortion,  and  will 
probably  recollect  that  the  ordinary  treatment  of  uterine  disease 
in  such  cases  is  very  unsatisfactory.  I  think  the  experienced  phy- 
sician will  be  able  to  think  of  a  condition  of  the  reproductive 
organs,  which,  without  any  history  of  the  case,  would  impress  his 
mind  as  one  favoring  abortion.  These  are  the  cases  for  the  two 
species  of  Viburnum. 

Ehus  is  indicated  by  the  usual  symptoms,  burning  pain  and  heat, 
structures  pinched. 

Apis  is  a  very  fine  remedy  in  some  cases.  Indications,  burning 
with  itching,  especially  of  the  bladder  and  urethra. 

Collinsonia  is  sometimes  a  remedy,  the  indication  being  a  sense  of 
heat,  rawness  and  contraction,  usually  about  the  anus  or  in  the 
rectum  (associated  with  hemorrhoids),  or  sometimes  at  the  entrance 
of  the  vagina. 

Cannabis  Indica  is  a  remedy  for  erethism  of  the  reproductive  or- 
gans, and  venereal  excitement. 

Staphysagria  is  a  remedy  where  there  is  fullness  of  tissue,  abun- 
dant mucoid  discharge,  and  dull  brooding  of  the  mind,  with  invol- 
untary outbursts  of  passion. 


INTRODUCTION.  29 

A  thorough  analysis  of  disease  is  essential  to  success  in  treatment. 
"We  may  have  a  series  of  cases  of  uterine  disease,  say  ulceration 
of  the  cervix,  no  two  of  which  will  require  the  same  treatment. 
Take  for  example  a  case  in  which  an  ulcer  is  the  source  of  unrest, 
deranging  the  innervation  and  circulation  of  the  uterus  ;  causing 
profuse,  prolonged,  or  painful  menstruation  ;  causing  contraction 
of  the  abdominal  muscles,  and  change  in  the  position  of  the  uterus 
and  associate  viscera  ;  deranging  the  innervation  of  the  stomach 
and  intestinal  canal,  and  the  urinary  apparatus  ;  and  possibly  in- 
fluencing the  spinal  cord  and  brain  in  an  unpleasant  manner. 
There  is  no  doubt  but  in  some  cases  an  entire  series  of  lesions 
have  their  origin  thus,  in  a  point  of  irritation  that  you  might 
cover  with  a  five  cent  piece.  Let  us  treat  this  case  with  the  stick 
Nitrate  of  Silver,  cleanliness  and  rest,  and  as  the  local  irritation  is 
thus  removed,  we  find  that  one  after  another  the  unpleasant 
sympathetic  wrongs  fade  away,  and  finally  with  the  healing  up  of 
the  ulcer,  the  patient  is  wholly  relieved. 

Such  results  have  been  frequently  obtained,  and  because  the  cura- 
tive influence  of  the  escharotic  has  been  so  marked  in  some,  phy- 
sicians have  employed  it  in  all  cases.  I  need  hardly  say  that  the 
failure  is  complete  in  some,  the  condition  of  the  patient  is  worse  in 
others,  and  in  still  others  there  is  but  a  palliative  influence.  It 
only  proves,  what  has  been  so  often  stated  in  these  pages,  that  we 
can  not  prescribe  for  names  of  disease,  or  adopt  anybody's  stereo- 
type or  recipe  practice. 

Take  another  of  these  cases,  the  ulcer  presenting  a  very  similar 
appearance,  but  the  patient  suffering  from  tensive  contractile  pain 
in  the  pelvis,  and  dysmenorrhoaa,  and  the  treatment  might  be 
wholly  different.  Now  we  prescribe  for  the  patient,  Macrotys, 
Pulsatilla,  Viburnum,  one  or  more,  using  simply  washes  for  cleanli- 
ness, and  giving  rest  to  the  reproductive  function  and  apparatus, 
and  our  patient  recovers  without  the  unpleasant  local  application. 

In  another  case,  the  menstrual  flow  recurs  every  two  or  three 
weeks,  the  period  is  prolonged,  and  the  discharge  too  free.  There 
may  be  hardly  a  pain  or  ache,  the  sensation  being  almost  wholly 
of  exhaustion.  The  patient's  face  is  pallid,  the  tongue  full  and 
pallid,  appetite  poor.  We  prescribe  Carbo-veg.  to  rectify  the  wrong 
of  the  menstrual  period  and  check  the  flow,  and  Cuprum  to  rec- 


30  INTRODUCTION. 

tify  wrongs  of  the  sympathetic  and  as  a  blood-maker,  and  the  pa- 
tient makes  a  quick  and  good  recovery. 

In  another,  with  seemingly  similar  lesion  of  the  cervix,  we  find 
the  uterus  low  in  the  pelvis,  and  the  patient  unable  to  take  exer- 
cise on  account  of  the  dragging  pain,  backache,  urinary  irritation, 
and  other  unpleasant  symtoms.  In  such  case  the  use  of  a  well 
adjusted  perineal  supporter,  and  the  movement  cure,  will  accom- 
plish the  desired  object. 

I  have  seen  an  intractable  ulcer  in  the  nursing  woman  get  well 
promptly  on  wenning  the  child  ;  just  as  I  have  seen  a  similar  case 
cured  by  non-intercourse,  sending  the  wife  away  to  her  friends  for 
two  or  three  months. 

Here  is  your  case  of  diseased  cervix  with  ulceration,  in  which  the 
patient's  tissues  look  old  and  lifeless,  and  evidently  both  waste  and 
nutrition  are  slow  and  imperfect  Evidently  a  sound  uterus  can 
not  be  made  in  this  diseased  body — what  shall  we  do?  The  object 
is  plain  :  we  wish  to  establish  active  waste  and  excretion,  and  get 
rid  of  this  old  body,  and  by  putting  the  digestive  apparatus  in 
good  condition,  and  giving  the  patient  the  materials  of  good  blood, 
get  an  improved  nutrition,  and  build  up  a  better  body. 

Going  back  a  step,  we  will  find  our  ulcerated  cervix  in  sympathy 
with  an  irritable  bladder  and  urethra ;  the  ulcer  may  be  the  cause 
of  this  urinary  irritation,  or  it  may  be  the  effect.  I  saw  a  case  two 
years  since,  in  which  the  uterine  disease  had  resisted  all  the  usual 
means,  yet  was  cured  with  Apis  and  Eryngium.  I  have  seen  ulcers 
of  the  cervix  associated  with  hemorrhoids,  and  promptly  benefited 
by  the  treatment  of  these.  Take  the  case  of  venous  fullness  and 
atony,  with  relaxed  perineal  tissues,  full  doughy  cervix,  and  I  would 
hardly  think  of  treating  the  case  without  Hamamelis. 

Supposing  now  this  ulceration  Avas  the  result  of,  and  associ- 
ated with  that  peculiar  condition  of  the  female  organs  that  simu- 
lates a  spermatoi-rhcea  of  the  male,  what  would  be  a  proper  treat- 
ment? It  is  true,  touching  the  ulcer  with  nitrate  of  silver  might 
greatty  relieve  the  nervous  disturbance,  in  addition  to  giving  local 
rest  and  an  opportunity  for  restoration  ;  but  it  is  just  as  true  that 
a  right  treatment  for  the  reproductive  lesion  is  necessary  to  effect 
a  cure  in  other  cases.  There  is  a  condition  almost  the  opposite  of 
this,  atony  of  the  reproductive  organs,  and  loss  of  venereal  appe- 


INTRODUCTION.  31 

tite,  in  which  the  stimulus  of  small  doses  of  Nux  and  Iodine  plays 
an  important  part  in  the  ease. 

But  it  is  quite  clear  that  the  one  topical  application,  Nitrate  of 
Silver,  Avill  not  answer  in  every  case.  Let  us  reserve  it  for  those 
of  erosion  and  superficial  ulceration,  with  undue  sensitiveness  of 
the  tissues,  and  irritation  of  the  nerves.  The  surface  gives  a  pe- 
culiar velvety  sensation  to  the  finger,  and  in  the  larger  number  of 
cases  will  show  abundant  red  granulations.  Let  us  take  Nitric 
Acid  for  the  deeper,  well  defined  ulcers,  with  hardness  and  thick- 
ening of  the  adjacent  tissues,  applying  it  with  the  pine  pencil. 
When  the  tissues  are  full  and  doughy,  with  abundant  secretion, 
we  employ  Carbolic  Acid  and  Glycerine.  Even  glycerine  itself, 
concentrated,  makes  an  excellent  application  when  the  cervix  is 
very  much  enlarged  and  gives  an  oedematous  sensation  to  the  touch. 
Persulphate  of  iron  is  an  excellent  application  in  some  cases,  espe- 
cially when  the  part  is  deep-colored,  and  the  ulcers  are  inclined  to 
bleed.  So  in  some  other  cases  we  get  more  relief  from  the  appli 
cation  of  Potash — sometimes  the  mild  Sesqui-carbonate  :  in  rare, 
old,  stubborn  cases,  the  Potassa  Fusa. 

Whilst  naming  these  local  applications,  I  must  still  insist  that 
the  larger  number  of  cases  can  be  cured  without  any,  and  that  the 
most  successful  treatment  is  based  upon  our  knowledge  of  specific 
remedies.  If  in  any  case  AVC  have  a  marked  indication  for  any 
single  drug,  or  for  two  or  three  remedies,  the  treatment  will  be 
pleasant  and  satisfactory.  If  there  is  no  such  indication,  then  we 
select  from  the  remedies  that  influence  the  part,  as  we  can  recog- 
nize a  local  indication,  or  know  their  physiological  action. 

But  whatever  plan  we  adopt  it  will  not  do  to  forget  that  right 
living  is  essential  to  success.  We  can  not  expect  a  cure  so  long  as 
a  cause  of  disease  exists,  and  neither  can  we  expect  to  make  a  sound 
organ,  or  have  a  sound  function,  in  a  diseased  or  impaired  body. 

With  regard  to  the  use  of  vaginal  injections  in  the  class  of  dis- 
eases under  consideration  it  is  well  to  speak  with  considerable  cau- 
tion. There  are  some  cases  in  which  they  are  markedty  benefi- 
cial, as  there  are  others  in  which  they  are  just  as  clearly  injurious, 
and  the  trouble  is,  that  it  is  very  difficult  to  distinguish  these  cases. 
Possibly  we  can  only  tell  by  the  result,  a  rather  unpleasant  way  of 
administering  remedies. 


32  INTRODUCTION 

In  many  cases  the  use  of  a  large  basin  of  water,  either  warm  or 
cold,  (but  gradually  getting  it  cooler  if  it  has  to  be  used  warm  at 
first,)  applied  with  the  hand,  the  woman  sitting  over  it,  will  be 
found  the  best  means.  Even  a  solution  of  Chlorate  of  potash,  or  a 
weak  astringent  wash  ma}T  be  used  in  this  way  with  advantage. 
But  in  the  larger  number,  all  that  we  want  is  cleanliness,  and  the 
strengthening  effect  that  may  be  obtained  from  the  use  of  water. 

Injections  have  a  very  \vide  range,  from  a  simple  weak  solution 
of  Chlorate  of  Potash  to  the  strong  vegetable  or  mineral  astringents. 
It  is  hardly  worth  while  to  give  formulas  for  them,  as  every  physi- 
cian will  find  in  his  text-books  the  common  prescriptions.  I  have 
used  an  infusion  of  equal  parts  of  Rum  ex,  Alnus  and  Quercus  Rubra 
with  excellent  effects  in  some  old  cases  of  vaginitis  and  ulceration, 
with  good  results,  and  I  have  also  used  Carbolic  Acid  and  Sulphur- 
ous Acid  in  others.  The  trouble  with  Carbolic  Acid  is  its  very 
unpleasant  odor,  and  in  place  of  this  I  use  the  new  remedy,  Salicy- 
lic Acid,  especiallj7  in  cases  where  there  is  fetid  discharge. 

I  wish  to  call  attention  to  the  advantages  of  hot  water  whenever 
there  is  relaxation  of  the  perineal  structures  and  abnormal  dis- 
charges. The  water  should  be  used  as  hot  as  it  can  be  borne — the 
patient  sitting  over  a  basin  containing  the  water,  and  sponging 
herself;  or  if  too  weak  for  this,  she  may  be  rapidly  sponged  by 
the  nurse.  It  has  proven  an  admirable  means  of  checking  hem- 
orrhage, and  in  profuse  leucorrhoeal  discharges. 

For  cleanliness  and  as  an  antiseptic  no  agent  will  be  found  supe- 
rior to  Borax.  Clothing,  or  anything  that  may  be  soiled  by  dis- 
charges, is  thoroughly  purified  \)j  washing  in  a  hot  solution  of 
borax.  It  may  be  added  to  the  water  used  as  a  bath,  and  if  the 
vaginal  discharges  are  fetid  it  should  be  used  as  a  wash  or  an 
injection.  In  all  operations  no  better  surgical  dressing  can  be 
found  than  a  solution  of  borax,  or,  if  a  dry  dressing  is  required 
than  the  powdered  boracic  acid. 


ON    THE 


DISEASES   OF   WOMEN. 


CHAPTER    I 


ANATOMY  OF  THE  FEMALE  ORGANS  OF  GENERATION. 

1.  IT  is  of  the  greatest  importance  to  the  student,  in  commenc- 
ing the  study  of  those  diseases  which  have  their   origin  in   the 
female  organs  of  generation,  and  a  majority  of  which  arise  from 
structural  changes,  that  he  shall,  first,  perfectly  master  the  anat- 
omy of  the  parts.     For  this  reason,  and  because  the  anatomy  of 
these   organs  is    seldom  studied   with    that  care    that    the    other 
portions  of  the  system  receives,  I  have  thought  it  necessary  to 
prefix   to   this   work,  a  concise  Anatomical   description  of   these 
organs ;    the  diseased  conditions  of  which  we  have  hereafter  to 
consider. 

2.  As  a  teacher  of  Anatomy,  I  have  had  to  regret  the  indiffer- 
ence manifested  by  students  of  medicine,  in  obtaining  a  correct, 
and,  as  I  might  say,  a  practical  knowledge  of   this   subject,  by 
means  of  dissection,  and  a  careful  examination  of  the  parts,  in  the 
dissecting-room.     There  are  no  other  means  by  Avhich  the  student 
can  obtain  that  knowledge  of  the  structure  and  relations  of  these 
organs,  their  normal  color,  consistence,  shape,  and  the  sensation 
given  to  the  touch;    without,  indeed,  he  expects  to  obtain  this 

3  (33) 


34  DISEASES    OF    WOMEN. 

information,  when  his  services  are  called  for  to  give  relief  in  some 
disease  of  these  organs.  And  yet  I  have  seen  many  leave  our 
halls,  and  commence  practice,  "who,  perhaps,  never  so  much  as 
examined  the  situation  of  the  orifice  of  the  urethra,  or  the  direc- 
tion of  its  canal ;  much  less  informing  themselves  in  the  dissect- 
ing-room, and  by  actual  experiment,  how  the  catheter  should  be 
introduced.  Yet  it  is  expected  that  they  will  be  able  to  perform 
this  operation,  sometimes  under  embarrassing  circumstances,  and 
when  probably  the  life  of  the  patient  is  at  stake.  This  is  only  a 
fair  illustration  of  the  necessity  of  this  practical  acquirement  of 
anatomical  knowledge,  in  order  to  fit  the  practitioner  to  meet 
every  requirement  on  his  skill. 

3.  I  would  then  urge  it  upon  every  one,  who  expects  to  succeed 
in  the  practice  of  medicine,  to  improve  every  opportunity  offered, 
of  making  himself  perfectly  familiar  with  the  structure  and  rela- 
tions of  these  organs ;    and  that  he  may  be  able   to   do  this,  to 
thoroughly  master  the  written  description. 

4.  The  female  organs  of  generation  are  classed  in  two  divisions 
— external  and  internal.     The  external  organs  consist  of  the  mons 
veneris,  labia  externa,   the  fourchette,  the  fossa  navicularis,  the 
clitoris,  the  nymphce,  and  the  hymen :   these  are  all  included  under 
the  general  term  of  vulva. 

The  internal  organs  are,  the  vagina,  the  uterus,  fallopian  tubes, 
and  the  ovaries. 


EXTERNAL  ORGANS. 

MONS  VENERIS. 

5.  This  is  that  rounded  eminence,  more  or  less  prominent  in 
different  individuals,  situated  immediately  anterior  to  the  sym- 
physis  pubis,  and  directly  above  the  vulva.  The  prominence  of 
this  part  is  partly  owing  to  the  bones,  but  more  to  a  large  quantity 
of  loose  cellular  tissue,  the  interstices  of  which  are  filled  up  with 
adipose  matter.  It  is  covered  by  the  common  integument,  and  at 
the  age  of  puberty  is  studded  with  numerous  short  hairs,  among 


L  A B 1  A     K  X  T  K  K  X  A  . 


the  roots  of  which  are  embedded  numerous  sebaceous  follicles. 
Its  use  is  not  known,  though  it  is  supposed  to  assist  in  the  dilation 
of  the  vulva  in  parturition,  owing  to  the  great  laxity  of  its  tissue  = 


FIG.  ] . — A  SIDE  VIEW  OF  THE  VISCERA  OF  THE  FEMALE  PELVIS. 

1.  The  syniphysis  pubis;  to  the  upper  port  of  which  the  tendon  of  the  rectus  muscle 
s  attached.  2.  The  abdominal  parietes.  3.  The  collection  of  fat,  forming  the  promi- 
nence of  the  mons  veneris.  4.  The  urinary  bladder.  5.  The  entrance  of  the  left 
ureter.  6.  The  canal  of  the  urethra,  converted  into  a  mere  fissure  by  the  contraction 
of  its  walls.  7.  The  meatus  urinarius.  8.  The  clitoris,  with  its  prasputium,  divided 
through  the  middle.  9.  Ihe  left  nymphse.  10.  The  left  labium  majus.  11.  The  meatus 
of  the  vagina,  narrowed  by  the  contraction  of  its  sphincter.  12.  22.  The  canal  of  the 
vagina,  upon  which  the  transverse  rugfe  are  apparent.  13.  The  thick  wall  of  separation 
between  the  base  of  the  bladder  and  the  vagina.  14.  The  wall  of  separation  between 
the  base  of  the  bladder  and  the  vagina.  15.  The  perineum.  16.  The  os  uteri.  17.  Its 
cervix.  18.  The  fundus  uteri.  The  cavitas  uteri  is  seen  along  the  center  of  the  organ. 
19.  The  rectum,  showing  the  disposition  of  its  mucous  membrane.  20.  The  anus.  21. 
The  upper  part  of  the  rectum,  invested  by  the  peritoneum.  23.  The  utero-vesical  fold 
of  peritoneum.  The  recto-uterine  fold  is  seen  between  the  rectum  and  the  posterior 
wall  of  the  vagina.  24.  The  reflexion  of  the  peritoneum,  from  the  apex  of  the  bladder 
upon  the  urachus  to  the  internal  surface  of  the  abdominal  parietes.  25.  The  last  lumbar 
vetebra.  28.  The  sacrum.  27.  The  coccyx. 

LABIA  EXTERN A  OR  MAJOR  A. 

6.  Extending  down  from  the  prominence  of  the  mons  veneris, 
are  two  prominent  cutaneous  folds,  inclosing  an  elliptical  fissure, 
the  common  sexual  opening,  or  vulva.  They  are  flattened  trans- 


36  DISEASES      OF      WOMEX. 

versely,  and  are  thicker  in  front  than  behind:  their  anterior 
extremities  are  continuous  with  the  mons  veneris ;  their  posterior 
extremities  unite  to  form  a  commissure,  called  the  four chette,  which 
is  almost  always  lacerated  in  the  first  labor.  Immediately  within 
his  commissure  is  a  small  cavity,  the  fossa  navicularis.  It  extends 
from  the  fold,  formed  by  the  union  of  the  labia,  to  the  entrance 
of  the  vagina.  The  constituent  parts  of  the  labia  majora  are,  a 
cutaneous  layer,  covering  their  external  surface,  a  mucous  layer, 
covering  their  internal  surface,  both  provided  with  numerous 
sebaceous  follicles.  Internally  they  consist  of  a  loose  areolar  tis- 
sue, which  is  more  or  less  loaded  with  adipose  matter.  There  is 
also  a  layer  of  dartoid  tissue  next  the  mucous  membrane,  and 
some  arteries,  veins,  lymphatics,  and  nerves.  The  external  sur- 
face of  the  labia,  as  well  as  their  free  convex  borders,  are  covered 
with  hair :  their  internal  surfaces  are  moist  and  smooth,  and  in 
contact  with  each  other. 

7.  The  use  of  the  labia  majora  is  to  favor  the  extension  of  the 
vulva  during  parturition,  for  in  the  passage  of  the  head  of  the 
child,  the  labia  are  unfolded  and  completely  effaced. 

NYMPHS. 

8.  The  nymphae,  or  labia  minora,  are  seen  after  separating  the 
labia  majora  under  the  form  of  two  layers  of  mucous  membrane; 
they  are  narrow  behind,  where  they  commence  upon   the  inner 
surface  of  the  labia  majora,  and  they  enlarge  gradually  as  they 
converge  toward    each  other  in  front;  at  the  clitoris  they  become 
slightly  contracted  and  bifurcate  before  their  termination.     The 
lower  division  of  the  bifurcation  is  attached  to  and  continuous 
with  the  glans  of  the  clitoris  ;   the  upper  division  unites  with  that 
of  the  opposite  side,  and  forms  a  hood-like  fold,  called  the  pre- 
putiv.m  clitoridis.     The    nymphae   are  provided  with  very  large 
crypts,  which  are  visible  to  the  naked  eye,  and  secrete  an  abund- 
ance of  sebaceous  matter.     Between  the  two  layers  of  mucous 
membrane  forming  the  nymphae,  is  found  a  layer  of  erectile  cellu- 
lar tissue,  which  may  be  said  to  constitute  its  proper  tissue.     The 
nymphae  vary  much  in  size,  according  to  age ;  thus,  in  new  born 
infants,  they  project   beyond   the   labia  majora,  principally  on. 


CLITORIS.  37 

account  of  the  imperfect  development  of  the  latter.  They  also 
vary  in  different  persons,  in  some  females  being  extremely  small, 
and  in  others  always  projecting  beyond  the  labia  majora;  and, 
lastly,  in  different  countries;  for  with  the  women  of  some  parts 
of  Africa  and  Asia,  as  is  well  known,  they  become  of  dispropor- 
tionate length,  and  protrude  beyond  the  labia  majora.  This 
peculiarity  of  structure  becomes  so  marked  as  to  constitute  an 
inconvenience  and  a  deformity,  and  has  led  to  the  adoption  of  a 
kind  of  circumcision. 

CLITORIS. 

9.  The  clitoris  is  a  spongious  vascular  erectile  organ,  forming 
a  miniature  representation  of  the  corpus  cavernosum  of  the  penis. 
Its  free  extremity  is  seen  in  the  anterior  part  of  the  vulva,  about 
six  lines  behind  the  anterior  part  of  the  labia  majora,  and  resem- 
bles a  tubercle  in  the  median  line,  covered  as  by  a  hood,  with  the 
upper  divisions  of  the  bifurcated  nymphee,  and  continuous  with 
the  lower  divisions  of  the  same.  This  free  extremity,  or  glans,  is 
covered  by  an  external  membrane,  on  which  ramify  a  vast  number 
of  nerves  derived  from  the  internal  pudic,  the  presence  of  which 
accounts  for  its  extreme  sensibility.  Like  the  corpus  cavernosum 
in  the  male,  the  clitoris  arises  from  the  ascending  rami  of  the 
ischia  by  two  roots,  which  expand  and  converge  until  they  arrive 
opposite  the  symphysis,  where  they  unite  and  form  a  single  corpus 
cavernosum,  flattened  on  each  side;  this,  after  passing  for  some 
lines  in  front  of  the  symphysis,  separates  from  it,  and  forming  a 
curve,  with  the  convexity  directed  forward  and  upward,  and  the 
concavity  directed  downward  and  backward,  gradually  becoming 
smaller  toward  its  free  extremity.  It  has  a  suspensory  ligament 
precisely  resembling  that  of  the  penis,  and,  like  the  penis,  it  is 
provided  with  two  small  muscles ;  the  eredores  clitoridis.  This 
structure  constitutes  the  clitoris  an  erectile  organ,  though  this 
property  in  the  healthy  and  normal  state,  is  confined  within  nar- 
row limits,  only  slightly  increasing  its  length  and  volume,  so  that 
it  never  passes  beyond  the  labia  majora.  Under  the  influence  of 
disease  or  irritation,  however,  and  sometimes  as  a  natural  con- 
dition, it  may  attain  a  considerable  size. 


38  DISEASES      OF      WOMEN. 

VESTIBULE. 

10.  Lying  immediately  between  the  crura  of  the  clitoris,  and 
running  downward  and  inward  round  the  lower  edge  of  the  svm- 

O  O  •/ 

physis  pubis,  is  situated  a  smooth  grove  about  an  inch  in  length, 
and  which  leads  directly  to  the  meatus  urinarius.  The  physician 
will  find  it  highly  important  to  pay  attention  to  this  depression, 
because  in  the  introduction  of  the  catheter,  it  will  guide  his  finger 
backward  to  the  orifice  of  the  urethra. 

MEATUS  URINARIUS. 

11.  The  meatus  urinarius,  or  the  external  orifice  of  the  urethra, 
is  situated  at  the  inner  extremity  of  the  vestibule,  and  about  an 
inch  or  an  inch  and  a  quarter  below  and  behind  the  clitoris,  and 
immediately  above  the  projecting  margin  of  the  opening  of  the 
vagina.     The  meatus  urinarius,  in  the  majority  of  females,  pre- 
sents a  projecting,  soft,  circular  elevation,  surrounded  by  numerous 
mucous  follicles,  and  can    be  easily  detected  when  the  finger  is 
introduced  backward  along  the  vestibule;  in  other  cases,  no  pro- 
jection is  found, — the  urethra  terminating  in  thin  and  membranous 
walls.     The  orifice  of  the  urethra  may  be  observed  as  a  central 
depression,  that  would  appear  scarcely  large  enough  to  admit  a 
probe ;    yet   it    is    very  dilatable, — admitting    the    largest    sized 
catheter  with  ease  ;  and,  under  the  influence  of  chloroform,  it  may 
be  dilated  so  as  to  admit  the  passage  of  quite  large  urinary  calculi. 

HYMEN. 

12.  In  virgins,  the  orifice  of  the  vulva  is  provided  with  a  mem- 
brane, concerning  the  form  and  existence   of  which  there  have 
been  numerous  disputes.     It  is  called  the  hymen,  and  is  a  sort  of 
diaphragm  interposed   between  the  internal  genitals  on  the  one 
hand,  and  the  external  genitals  and  urinary  passages  on  the  other. 
This  membrane  is  generally  crescentic  in   shape, — the    aperture 
being  at  the  upper  part  of  it ;    though  sometimes  it  is  circular, — 
the  aperture  being  in  the  center.     Its  free  margin  is  fringed ;  it 
varies  in  breadth  in  different  individuals,  and  thus  regulates  the 
dimensions  of  the  vaginal  orifice.     The  hymen  has  frequently  been 
found  without  a  perforation,  and  has  therefore  prevented  the  dis- 


THE     IIYMKX.  39 

charge  of  the  menstrual  secretion.  It  is  generally  ruptured  in 
the  first  intercourse  of  the  sexes  :  and  some  small  tubercles,  which 
are  found  on  the  surface  of  the  vagina  near  the  spot  where  it  was 
situated,  are  supposed  to  he  the  remains  of  it.  These  tubercles, 
which  vary  from  two  to  five,  are  called  Caninculce  Myrtiformes. 

li>.  The  hymen  is  composed  of  a  duplicaturc  of  mucous  mem- 
brane, varying  in  strength,  and  containing  within  it  some  cellular 
tissue  and  vessels.  The  mucous  membrane  lining  the  vulva  is 
continuous  on  the  one  hand,  with  the  skin  at  the  internal  surface  of 
the  labia  majora,  and  with  the  mucous  membrane  of  the  vagina  on 
the  other;  upon  the  labia  majora  and  nymphne,  it  has  a  great 
number  of  sebaceous  follicles,  visible  to  the  naked  eye,  and  yielding 
a  cheesy,  odorous  secretion ;  and  also  mucous  follicles,  which  are 
most  numerous  near  the  meatus  urinarius,  the  orifices  of  which 
are  visible  to  the  naked  eve,  and  are  often  laro;e  enough  to  admit 

*/       >  O  O 

the  blunt  extremity  of  a  probe. 

14.  In  addition  to  these  mucous  follicles,  destined  to  lubricate 
the  parts  and  protect   them   from  injury,   are  the  large  mucous 
glands,  called   the  glands  of  Bartholine,  or    the  Vulvo-  Vaginal 
glands.      These   are   situated  at  the  sides   of   the  vagina,  at  the 
union  of  the  upper  two-thirds  of  the  vaginal  orifice  with  the  lower 
third.     The  duct  by  which  they  empty  themselves  is  about  half  an 
inch  in  length,  and  opens  at  the  side  of  the  hymen.     The  mucus 
secreted  by  the  follicles  of  the  vulva,  and  by  the  vulvo-vaginal 
glands,  is  transparent  and  viscid,  and,  like  the  mucus  secreted  in 
the  vagina,  it  has  an  acid  reaction, — reddening  blue  litmus  paper. 

15.  All   the   parts  immediately  within  the  genital   fissure   are 
profusely  supplied  with  blood  from  branches    derived   from   the 
internal  and   external    pudics,   and  abturator  arteries,  and   with 
nervous    filaments    from   the    inguinal    branches    of    the    lumbar 
plexus,  and  the  internal  pudic  nerve.     The  lymphatics  of  these 
organs  are  also  very  numerous,  and,  like  the  lymphatics  of  the 
external  genital  organs  of  the  male,  they  open  into  the  inguinal 
lymphatic   glands.     So  that  diseases  of  the  labia,  nyrnphse,  and 
clitoris,  like  those  of  the  prepuce,  penis,  and  scrotum,  occasion 
enlargement  of  these  glands. 


40  DISEASES     OF     TVOMEX. 

INTERNAL  ORGANS  OF  GENERATION. 

THE  VAGINA. 

16.  The  vagina  is  a  membranous    canal   extending   from   the 
vulva  to  the  uterus ;  it  is  the  female  organ  of  copulation,  and  also 
forms  the  passage  for  the  menstrual  blood   and  the  product  of 
conception. 

17.  It  is  situated  in  the    cavity  of    the  pelvis,   between   the 
bladder  and  rectum,  and  is   held  in  that  situation   by  tolerably 
close  adhesions  to  the  neighboring  parts.     It  is  directed    upward 
and  backward,    and  coincides  with  the  axis  of  the  outlet  of  the 
pelvis ;  and,  as  the  direction  of  the  uterus  corresponds  with  the 
axis  of  the  brim,  these  two  parts  form  an  angle  or  curvature  with 
each  other, — having  its  concavity  directed  forward.     The  vagina 
is  shaped   like   a  cylinder  flattened   from  before  backward,  and 
having  its  walls  in  contact,  as   may  be  seen    by  applying  the 
speculum.     Its  length  is  variable,  but  it  is  always  longer  upon  the 
posterior  than  upon  the  anterior  wall.     The  former  being  usually 
about  five  or  six  inches  in  length,  and  the  latter,  four  or  five.    The 
vagina  is  not  of  the  same  diameter  throughout.     Its  lower  orifice 
is  the  narrowest  part,  while  its  upper  extremity  is  the  widest.     In 
females  who  have  borne  children,  the  upper  part  of  the  vagina 
forms  a  large  ampulla,  in  which  the  speculum  may  be  moved  about 
extensively,  and  in  which  also  a  considerable  quantity  of  blood  may 
accumulate  during   hemorrhage.     It  is,  likewise,  a  very  dilatable 
canal,  as  is  proved  during  parturition,  and  is,  at  the  same  time, 
elastic,  and  contracts  after  delivery,  so  as  almost  to  return  to  its 
original  dimensions.     It  would  appear  also  to  be  capable   of  a 
vermicular  contraction. 

18.  Relations. — In  front,  where  it  is  slightly  concave,  it  corres- 
ponds to  the  inferior  fundus  of  the  bladder,  to  which  it  is  united  by 
a  very  dense  filamentous  cellular  tissue,  resembling  the  dartos  of 
the  scrotum  ;  it  can  not  be  separated  from  the  urethra,  which  ap- 
pears to  be  hollowed  out  in  the  substance  of  its  walls.  The  close 
adhesion  of  the  vagina  to  the  bladder  and  urethra,  accounts  for 


THE      VAGINA.  41 

these  latter  organs  always  following  the  uterus  and  vagina  in 
their  displacements.  Behind,  the  vagina  corresponds  to  the  rec- 
tum, through  the  medium  of  the  peritoneum  in  its  upper  fourth, 
and,  immediately,  in  its  lower  three-fourths.  It  adheres  to  the 
rectum  by  cellular  tissue  resembling  the  clartos,  and  analogous  to 
that  existing  between  the  bladder  and  the  vagina,  though  much 
looser;  so  that  the  rectum  is  not  near  so  liable  to  follow  the 
vagina  in  its  displacement  as  the  bladder.  The  sides  of  the 
vagina  give  attachment  to  the  broad  ligaments  above,  and  to  the 
superior  pelvic  fascia  and  the  levatores  ani  below,  and  they  are 
in  relation  writh  the  cellular  tissue  of  the  pelvis,  and  with  some 
venous  plexuses.  The  upper  extremity  of  the  vagina  embraces 
the  neck  of  the  uterus,  which  projects  into  the  cavity,  and  upon 
which  it  is  prolonged,  without  any  line  of  demarkation, — forming 
a  circular  trench  around  the  os  tincea,  which  is  deeper  behind 
than  in  front.  The  lower  extremity,  or  vulva,  presents  a  cor- 
rugated, transverse  projection  in  front,  which  is  exposed  by  sepa- 
rating the  labia  and  nymphge :  it  narrows,  and  seems  even  to  close 
the  entrance  of  the  vagina. 

19.  Structure. — In  structure  the  vagina  is  composed  of  an  exter- 
nal tunic  of  contractile  fibrous  tissue,  a  middle  layer  of  erectile  tissue, 
and  an  internal  lining  of  mucous  membrane.  The  exterior  contrac- 
tile fibrous  tissue  is  a  dense,  cellular  structure,  of  a  lightish  color, 
and  has  some  resemblance  to  the  texture  of  the  body  of  the  uterus. 
It  is  very  vascular,  and  may  be  greatly  distended,  and  seems  to 
have  a  contractile  power,  and,  from  the  presence  of  this,  an  obscure 
vermicular  motion  may  take  place,  and  assist  the  elasticity  of  the 
walls  of  the  vagina.  This  external  layer  serves  to  connect  the 
vagina  to  the  surrounding  viscera.  The  middle,  or  erectile  layer, 
constitutes  the  proper  membrane  or  tube  of  the  vagina;  it  ia 
enclosed  between  the  two  layers  of  fibrous  membrane,  and  ia 
thickest  near  the  commencement  of  the  vagina,  and  becomes 
gradually  thinner  as  it  approaches  the  uterus.  At  the  commence- 
ment of  the  vagina,  there  is  in  front,  and  on  each  side  of  this 
orifice,  an  enlargement,  or  cavernous  body,  from  three-fourths  to 
an  inch  in  breadth,  which,  when  cut  in  two,  resembles  the  corpora 


42  DISEASES     OF     WOMEN. 

cavernosa,  or  the  corpus  spongiosus  of  the  penis,  and  hence  it  has 
been  called  the  Corpora  Cavernosa  Vagince.  It  consists  of  the 
same  erectile  vascular  tissue  which  forms  the  middle  layer  of  the 
vagina.  These  bodies  commence  near  the  body  of  the  clitoris, 
and  extend  downward  on  each  side  of  the  vagina, — occupying  the 
interval  between  the  entrance  of  the  vagina  and  the  roots  of  the 
clitoris.  They  are  not  very  thick  in  the  center,  where  they  unite 
between  the  meatus  urinarius  and  the  union  of  the  roots  of  the 
clitoris ;  but  they  gradually  enlarge  from  this  point,  and  terminate 
below,  upon  the  sides  of  the  vagina,  by  enlarged  extremities, — the 
posterior  part  of  the  wall  of  the  vagina  being  the  only  portion  not 
covered  by  them.  These  erectile  bodies  are  covered  by  the  muscu- 
lar fibers  forming  the  sphincter  vagina,  which  pass  over  them  on 
each  side,  from  the  sphincter  ani  to  the  body  of  the  clitoris,  to 
each  of  which  they  are  attached. 

20.  The  mucous  membrane  which  lines  the  vagina,  appears  to 
be  intermediate  between  those  membranes  which  secrete  mucus  in 
different  parts  of  the  body,  and  the  skin.     It  is  covered  with  a 
squamous  epithelium,  which  can  be  very  easily  demonstrated,  and 
which  is  prolonged  as  far  as  the  os  uteri,  where  it  terminates  by  a 
sort  of  indented  margin,  changing  its  character  to  the  ciliated 
epithelium  of  the  uterus.     The    internal  surface    of    the  vagina 
presents  on  both  walls,  but  especially  in  front  and  near  the  orifice 
of   the  vulva,  some    transverse  rugae,  which  extend  outward  on 
each  side  from  a  middle  raphe.     These  rugae  and  raphe  are  more 
prominent  on  the  anterior  than  on  the   posterior  wall  of  the  va- 
gina, and  the  two  raphe  are  called  the  columnar  of  the  vagina. 
This  arrangement  of  the  surface  of  the  vagina  does  not  extend 
beyond  the  external  half  of  the  canal ;  on  the  internal  half,  or 
that  next  to  the  uterus,  the  surface  is  smooth. 

21.  Throughout  this  surface  are  to  be  seen,  in  some  cases  with 

O  7 

the  naked  eye,  the  orifices  of  numerous  mucous  follicles  or  ducts, 
which  occasionally  discharge  considerable  quantities  of  mucus, 
which  is  white,  creamy  and  fluid,  having  an  acid  reaction,  red- 
dening blue  litmus  paper;  and  it  contains  numerous  lameliform 
corpuscles,  the  result  of  a  kind  of  exfoliation  of  the  epithelium. 
The  vagina  is  abundantly  supplied  with  blood  from  the  proper 


THE     UTKKUS.  43 

vaginal  arteries,  which  arise  from  the  hypo-gastric.  It  also  receives 
numerous  branches  from  the  uterine  arteries.  Its  veins  are 
very  numerous,  forming  plexuses  around  it ;  they  accompany  the 
arteries,  and  terminate  in  the  hypogastric  veins.  The  lymphatics 
are  also  numerous,  passing  oft'  in  two  directions ;  one  division 
passing  off  to  the  inguinal  lymphatic  glands,  the  other  to  the 
lymphatic  glands  lying  upon  the  sides  of  the  anterior  surface  of 
the  sacrum. 

22.  The  vagina  is  abundantly  supplied  with  nerves,  which  are 
derived  from  two  sources ;  it  receives  its  spinal  nerves  from  the 
sacral  plexus,   being    supplied    by  the   visceral  branches,   which 
ascend  upon,  the  side  of  the  rectum,  vagina,  and  bladder,  furnish- 
ing nervous  filaments  to  each  of  these  organs,  interlacing  with  the 
branches  of  the  hypogastric  plexus.     It  receives  its  sympathetic 
nerves  from  the  descending  uterine  nerves  derived  from  the  hypo- 
gastric  plexus ;  these  branches  run  along  the  sides  of  the  vagina, 
and  appear  to  be  inseparably  blended  with  the  spinal  filaments 
described  above. 

THE    UTERUS. 

23.  The  uterus,  matrix,  or  womb,  is  the  organ  of  gestation, 
destined  to  receive,  to  afford  lodgment  and  nourishment  to,  and 
eventually  to  expel  the  ovum. 


FIG.  2. — THE  UTERUS,  OVARIES,  FALLOPIAX  TUBES  Aur  LATERAL  LIGAMENTS. 

It  is  a  flattened  organ  of  a  pyriform  shape,  having  the  base 
directed  upward  and  forward,  and  the  apex  downward  and  back- 
ward, in  the  line  of  the  axis  of  the  inlet  of  the  pelvis,  and  forming 


44 


DISEASES     OF     WOMEX. 


a  considerable  angle  with  the  vagina.  Its  direction  is  liable  to 
frequent  variation,  owing  to  the  looseness  and  extensibility  of  its 
connections,  Avhich  enables  it  to  float,  as  it  were,  in  the  cavity  of 
the  pelvis,  and  to  be  moved  to  a  greater  or  less  extent.  These 
variations  in  its  direction  become  causes  of  disease,  and  will  be 
hereafter  considered.  There  is  one  deviation  that  frequently 
occurs — so  very  frequently  indeed  that  it  has  been  considered 
natural — and  appears  to  be  connected  with  the  position  of  the 
rectum  on  the  left  side  of  the  pelvis.  The  uterus  occupies  a 
diagonal  position,  lying  from  right  to  left,  so  that  the  fundus  is 
directed  toward  the  right  ilium,  and  the  cervix  toward  the  left 
groin.  In  pregnancy,  this  deviation  is  almost  constant,  and  has 
probably  some  relation  with  the  usual  position  of  the  child,  \ir/. : 
that  in  which  the  occiput  is  turned  toward  the  left  acetabulum  of 
the  mother.  This  fact  should  be  borne  in  mind,  as  ignorance  of  it 
might  lead  to  errors  in  diagnosis. 

24.  Size. — In  the  unimpregnated  state  it  is  about  three  inches  in 
length,  two  in  breadth  across  its  broadest  part,  and  one  in  thick- 
ness. This  is  about  the  average  size  in  the  fully  developed  female, 
but  it  varies  according  to  age,  and  certain  physiological  conditions 
peculiar  to  this  organ.  Thus,  it  is  very  small  until  puberty,  and 
then  acquires  the  size  which  it  subsequently  presents.  In  females 


FIG.  8. — THE  VIRGIN  UTERUS. 


FIG.  4. — THE  POST-PARTUM  UTERUS. 


TIIK      UTERUS.  45 

who  have  borne  children,  it  never  returns  to  its  usual  size.  It 
becomes  enormously  enlarged  during  pregnancy,  being,  when 
labor  is  near  at  hand,  about  thirteen  inches  long,  and  eight  or 
nine  across ;  it  also  becomes,  sometimes,  much  enlarged  from  the 
development  of  certain  tumors  within  its  cavity.  In  old  age  it 
becomes  atrophied  and  is  sometimes  as  small  as  in  new-born 
infants.  The  iveiglit  of  the  uterus  is  from  eight  to  ten  drachms 
at  puberty,  an  ounce  or  an  ounce  and  a  half  in  females  who  have 
borne  children,  from  two  to  six  drachms  in  old  age,  when  it 
becomes  atrophied,  and  at  the  end  of  pregnancy  from  a  pound 
and  one-half  to  three  pounds. 

25.  The  uterus  is  divided  by  most  anatomists  into  fundus, 
body,  cervix  or  neck,  and  os  uteri  or  tincea,  or  mouth  of  the  womb. 
The  fundus  of  the  uterus,  is  that  part  of  the  organ  that  rises 
above  the  insertion  of  the  fallopian  tubes ;  it  is  convex,  directed 
upward  and  forward,  and  is  completely  invested  by  the  perito- 
neum, and  is  covered  by  the  convolutions  of  the  small  intestine. 
When  not  distended  it  never  rises  as  high  as  the  brim  of  the 
pelvis,  and  can  not  therefore  be  felt  in  the  hypogastric  region. 
But  it  may  be  elevated  by  the  finger  introduced  into  the  vagina, 
or  by  the  uterine  sound,  so  that  it  can  be  felt  through  the  abdom- 
inal parietes.  The  body  of  the  uterus  is  that  part  below  the 
insertion  of  the  fallopian  tubes,  and  above  the  constriction  which 
marks  the  commencement  of  the  cervix.  The  boundary  between 
the  fundus  and  body  is  entirely  arbitrary,  there  being  no  differ- 
ence either  in  structure  or  form,  sufficient  to  justify  this  division. 
I  have  given  it,  however,  to  prevent  any  misapprehension  on  the 
part  of  the  reader.  The  body  of  the  uterus  is  situated  between 
the  bladder  and  rectum,  with  which  it  is  united  by  folds  or  plaits 
of  the  peritoneum,  reflected  from  it  anteriorly  to  the  bladder, 
and  posteriorly  to  the  rectum :  these  anterior  and  posterior  folda 
are  two  in  number,  between  the  uterus  and  rectum,  and  two 
between  the  uterus  and  bladder;  they  are  called  the  Anterior  and 
Posterior  Ligaments  of  the  Uterus.  The  peritoneum  covering  the 
uterus,  is  also  reflected  from  it  to  the  sides  of  the  pelvis,  forming 
the  broad  ligaments,  which  divides  the  cavity  of  the  pelvis  into 
two  chambers,  an  anterior  and  posterior ;  the  anterior  containing 


46  DISEASES     OF    AYOMEX. 

the  bladder,  the  posterior  the  rectum   and   almost   always  some 
intestinal  convolutions. 

26.  The  cervix  is  the  lower  part  part  of  the  organ  ;  it  is  dis- 
tinguished from  the  body  by  a  well  marked  constriction.     It  is 
from  one  inch  to  an  inch  and  a  quarter  in  length  in  adult  females, 
who  have  never  borne  children,  but  it  has  in  some  instances  been 
seen  as  much  as  three  inches  in  length.     In   females  who  have 
borne    many  children,  the    cervix    is    shortened,    especially    that 
•portion  which  projects  into  the  vagina,  which  will  be,  sometimes, 
found   entirely  deficient.      The   cervix   of  the   uterus   is   divided 
externally  into  two  portions,  by  the  insertion  of  the  vagina.     The 
inferior  of  these  portions  protrudes  into  the  vagina,  and  is  called 
the  intra-vaginal :  the  superior  portion  is  between  the  insertion  of 
the  vagina,  and  the  body  of  the  uterus,  and  is  called  the  supra- 
vaginal.     This  superior  portion  of  the  cervix  is  in  contact  anteri- 
orly with  the  lowest  portion  of  the  posterior  wall  of  the  bladder, 
and  is  connected  to  it  by  cellular  tissue  for  the  distance  of  about 
half  an   inch,  or   between   the   insertion   of  the  vagina  and   the 
reflection   of  the   peritoneum,   from    the   uterus   to   the    bladder. 
Posteriorly,  the  supra-vaginal   portion  of  the   cervix  receives  a 
complete  investment  of  peritoneum.     The  orifice  at  the  termina- 
tion of  the  intra-vaginal  portion  of  the  cervix,  forms  the  os  uteri 
or  os  tincce,  through   which   a   free  communication   is  permitted 
between  the  cavities  of  the  vagina  and  the  uterus. 

27.  The  orifice  of  the  os  uteri,  in  the  virgin,  is  a  small  circular 
opening,  dividing  the  extremity  of  the  cervix  into  an  anterior  and 
posterior  lip,  the  anterior  lip  of  which  is  rather  fuller  and  thicker 
than  the  posterior.     After  parturition  this  opening  is  transverse, 
and  much  larger,  and  is  generally  fissured.     The  sensation  con- 
veyed by  bringing   the  pulp   of  the  finger  in  contact  with  the 
extremity  of  the  nose,  is  similar  to  that  of  bringing  the  finger  in 
contact  with  the  os  uteri.     In  the  healthy  state  the  intra-vaginal 
portion   of  the  cervix  uteri   is  smooth,   soft,   and  of  a  varying 
degree  of   elasticity,  owing  to  the  presence  or  absence  of  local 
congestion,  and  is  of  a  pale  rose  color.     There  is  also  complete 
absence  of  pain  on  pressure. 

28.  In  the  body  of  the  uterus  is  a  cavity  lined  by  mucous 


THE     UTERUS. 


47 


membrane;  its  walls  are  in  contact  and  are  smooth  and  covered 
with  a  layer  of  mucus.  The  interior  of  the  uterus  does  not  pre- 
sent, however,  a  single  cavity  connected  with  the  vagina  by  a 
canal  through  the  cervix,  as  it  has  been  described,  but  it  consists 
of  two  cavities.  These  cavities  will  be  considered  separately. 


FIG.  5. — THE  CAVITIES  OF  THE  UTERUS  AND  CERVIX,  IN  THEIR  NORMAL  CONDITION. 

29.  The  cavity  of  the  body  of  the  uterus,  is  of  a  triangular 
form,  and  has  an  opening  at  each  angle.  The  inferior  opening 
leads  into  the  canal  of  the  cervix,  and  at  this  point  there  is  a 
natural  stricture  that  closes  the  cavity  of  the  ut,erus.  This  con- 
striction of  the  internal  orifice  of  the  canal  of  the  cervix  may  be 
readily  ascertained  by  introducing  the  uterine  sound,  the  instru- 
ment passing  freely  through  the  lower  portion  of  the  canal,  but 
meeting  with  considerable  resistance  at  about  an  inch  or  an  inch 
and  a  quarter  above  the  os.  This  inferior  opening  is  frequently 
obliterated  in  females  who  have  passed  the  age  of  child-bearing, 
The  orifices  at  the  superior  angles,  are  those  of  the  fallopian 


48  DISEASES      OF      WOMEN. 

tubes,  they  are  scarcely  visible  to  the  naked  eye.  and  are  situated 
at  the  bottom  of  two  funnel-shaped  cavities,  which  represent  the 
original  bicornute  condition  of  the  organ.  This  triangular  cavity 
is  only  seen  when  the  organ  is  divided  from  side  to  side.  In  an 
antero-posterior  division  of  the  body  of  the  uterus,  the  cavity 
resembles  somewhat  the  cavity  of  the  cervix. 

The  cavity  of  the  cervix  represents  a  cylinder  flattened  from 
before  backward,  and  has  upon  its  anterior  and  posterior  walls,. 
in  the  median  line,  a  longitudinal  prominence  or  crista,  to  which 
numerous  oblique  folds  converge;  this  appearance  has  been  named 
the  arbor  vitce  uterina.  It  generally  disappears  after  the  first 
labor,  at  least  in  part,  the  folds  being  not  so  prominent ;  yet  it 
is  not  unfrequently  found  as  perfect  as  in  the  virgin  uterus. 
Between  these  folds,  are  numerous  mucous  follicles,  the  closure  of 
which,  and  their  subsequent  distension  by  the  accumulation  of  their 
proper  secretion,  gives  rise  to  that  vesicular  appearance  so  often 
noticed  within  the  os  and  cervix  uteri,  and  which  was  mistaken  by 
Naboth  for  ova,  hence  they  are  called  the  Uvula  of  Naboth. 


Fia.  6. — THE  TISSUES  OF  THE  UTERUS. 

pp  The  muscular  tissue;  m  m  the  internal  lining  or  mucous  membrane;  o  t  a  tubular 
gland. 


T  II  E     U  T  E  R  U  S  .  49 

30.  Structure. — The  constituent  parts  of  the  uterus   are,  an 
external  peritoneal  coat,  an  internal  lining  of  mucous  membrane, 
and  the  proper  tissue  of  the   uterus,  situated  between  these  two, 
together  with  the  uterine  arteries,  veins,  lymphatics  and  nerves. 

The  external  investment  or  coat  of  peritoneum  has  been  already 
described.  It  forms  a  complete  coat  to  all  that  part  of  the  uterus 
situated  above  the  insertion  of  the  vagina,  with  the  exception  of  a 
space  of  about  half  an  inch  on  the  anterior  portion  of  the  cervix, 
which  is  connected  by  cellular  tissue  to  the  base  of  the  bladder. 

Mucous  MEMBRANE. 

31.  The  lining  membrane  of  the  uterus,  differs  considerably 
from  all  other  mucous    structures  in  the  body.     This  difference 
consists  in  the  absence  of  all  sub-mucous  cellular  tissue,  the  mu- 
cous membrane  forming  a   part  of  the  uterine  walls,   and  being 
continuous  with  the  proper  tissue  of  the  organ.     This  difference 
of  structure,  and  the  great  difficulty  in  its  dissection,  has  caused 
many   anatomists  to  deny  its  existence.     In  proof  of  the  exist- 
ence of  this  membrane  Cruvelheir  offers   the  following  considera- 
tions :  "  First,  every  organized  cavity  which  communicates  with 
the  exterior  is  lined  by  mucous  membrane  :  why,  therefore,  should 
the  uterus  form  an  exception  to  this  rule  ?     Secondly,  by  dissec- 
tion, it  is  shown  that  the  mucous  membrane  of  the  vagina  is  con- 
tinued into  the  neck  of  the  uterus,  and  then  into  the  body.     Not- 
withstanding the  difficulty  of  dissecting  this  membrane,  on  account 
of  its  tenuity  and  its  close  adhesion  to  the  tissue  of  the  uterus, 
its  presence  is  demonstrated  by  the  following  observations  :     Un- 
der the  microscope,  the  internal  surface  of  the  uterus  presents  a 
papillary  appearance,  but  the  papillae  are  very  small ;  it  is  pro- 
vided with  follicles  or  crypts,  from  which  mucus  may  be  expressed 
by  a  number  of  points,  and  which  form  small  vesicles  when  dis- 
tended with  mucus,  in  consequence  of  obstruction  or  obliteration 
of  their  orifices.      Thirdly,  it  is  extremely  vascular,  and  presents  a 
capillary  net-work  of  the  same  appearance  as  that  of  other  mucous 
membranes;  and,  Lastly,  it  is  constantly  lubricated  with  mucus. 
Pathological  observations  also  show  that  the  internal  surface  of 
the  uterus,  like  all  mucous  membranes,  is  liable  to  spontaneous 


50  DISEASES     OF     WOMEN. 

hemorrhages,  from  exhalation,  without  breach  of  continuity,  to 
catarrhic  secretions,  and  to  those  growths  which  are  denominated 
mucous,  vesicular  and  fibrous  polypi ;  and  it  is  generally  admitted 
that,  where  there  is  an  identity  of  disease,  there  is  also  identity  of 
structure." 

32.  This  uterine  mucous  membrane  constitutes  from  one-fifth  to 
one-fourth  of  the  entire  thickness  of  the  uterine  wall.     Thus  the 
thickness  of  the  entire  uterine  wall  being  from  five  to  six  lines,  the 
thickness  of  the    mucous   membrane    would  be   about  one  line. 
The  adherent  surface,  as  we  have  seen,  is  so  closely  attached  to  the 
proper  tissue  of  the  uterus,  as  to  be  with  great  difficulty  dissected ; 
the  free  surface  is  smooth,  of  a  pale  rose  color,  and  furnished  with 
a   ciliated  epithelium,  and  numerous  mucous  follicles.     On  exam- 
ining this  surface,  with  the  microscope,  numerous  minute  points 
may  be  seen,  dotting  it  in  its  whole  extent.     These  are  the  orifices 
of  simple  tubular  glands  :  they  are  mostly  less  than  one-fourth  of 
an  inch  in  length,  and  arranged  by  the  side  of  each  other  like 
basaltic  columns;  they  are  not  all,  however,  straight,  some  being 
sinuous  or  vermiform.     It  is   supposed  that  these  glands  form  the 
deciduous  membrane,  and  furnish  the  menstrual  secretion. 

33.  The  mucus  secreted  by  the  uterus  is  transparent  and  viscid, 
resembling  the  mucus  secreted  by  other  mucous  membranes.    That 
secreted  in  the  cervical  canal  is  peculiarly  viscid  and  tenacious, 
transparent,  and  of  a  whitish  color.     This  mucus  has  an  alkaline 
reaction,  bringing  back  the  blue  color  of  red  litmus  paper,  and  is 
thus   distinguished  from  the    vaginal  mucus,  which  has  an   acid 
reaction. 

34.  The  proper  tissue  of  the  uterus  is  of  a  grayish  color,  very 
dense  and  strong,  and  creaks  under  the  knife  like  cartilage.     It 
is  composed  of  fibers,  the  nature  and  arrangement  of  which  it  is 
impossible  to  determine  in  its  ordinary  condition.     It  is  only  when 
it  is  enlarged  by  gestation,  that  the  true  character  of  the  uterine 
tissue  and  the  arrangement  of  its  fibers  become    apparent.     At 
this  time  its  tissue  is  soft,  reddish,  very  dilatable,  contractile  and 
presents  all  the  characteristics  of  muscular  tissue.     Its  fibers  are 
then  arranged  in  the  following  manner :  In  the  body  the  external 
thin  layer  is  composed  of  two  median  vertical  fasciculi,  one  on  each 


THE     UTERUS.  51 

surface  of  tlic  uterus;  of  a  second  fasciculus  which  runs  along  the 
superior  border  of  the  fundus,  and  of  several  oblique  ascending 
and  descending  fasciculi  which  converge  to,  and  may  be  traced 
upon,  the  fallopian  tubes,  round  ligaments  and  ligaments  of  the 
ovaries.  This  first  or  superficial  layer  belongs  exclusively  to  the 
body  of  the  uterus.  The  second  or  deep-seated  layer  of  the  body 
consists  of  two  series  of  circular  fibers;  these  form  two  cones, 
which  are  connected  by  their  bases  upon  the  median  line,  the 
fibers  blending  together,  and  by  their  apices  to  the  fallopian 
tubes.  The  neck  of  the  uterus  is  composed  entirely  of  circular 
fibers,  which  decussate  each  other  at  very  acute  angles,  and  are 
closely  compacted  together.  The  structure  of  the  cervix  differs 
from  that  of  the  body  of  the  uterus,  by  the  presence  of  a  greater 
amount  of  cellular  tissue  and  a  greater  degree  of  vascularity. 

35.  The  uterus  is  very  liberally  supplied  with  blood-vessels. 
Its  arteries  are  derived  from  two  sources;  the  principal  called 
the  uterine  arteries,  arises  from  the  hypogastric;  the  other  set, 
the  spermatic,  arise  from  the  aorta  as  they  do  in  the  male, 
descending  with  tortuous  inflexions;  they  supply  the  ovaries, 
then  passing  along  the  broad  ligaments,  they  distribute  their 
terminal  branches  to  the  uterus.  The  branches  of  both  sets  are 
very  tortuous. 


FIG.  7. — THE  VESSELS  OF  THE  UTERUS. 


36.    The  veins  follow  the  course  of  the  arteries;  the  spermatic 
veins,  ascending  with  the  spermatic  arteries,  terminate  as  they  do 


10  DISEASES     OF     WOMEN. 

in  the  male ;  the  right  in  the  ascending  vena  cava,  the  left  in  the 
renal  vein.  The  uterine  veins  empty  themselves  into  the  internal 
iliacs.  These  veins  are  remarkable  for  their  large  size,  durin^ 

O  O 

pregnancy  and  after  parturition.  The  term  uterine  sinuses  has 
been  given  to  the  large  veins  then  found  in  the  substance  of  the 
organ  ;  and  this  term  is  not  without  foundation,  for  these  venous 
canals  are  formed  by  the  lining  membrane  of  the  veins,  which 
adheres  to  the  proper  tissue  of  the  uterus,  just  as  in  the  sinuses 
of  the  dura  mater;  it  adheres  to  the  fibrous  tissue  of  that  organ. 

7  O 

LYMPHATICS. 

37.  Cruvelheir  gives  the  best  description  of  these  vessels  that 
I  have  seen.  He  says  :  "  Having,  in  diseases  of  the  uterus  inci- 
dental to  the  puerperal  state,  frequently  detected  pus  in  the  lym- 
phatics of  the  uterus,  I  have  been  enabled  to  trace  the  exact 
distribution  of  these  vessels,  and  would  divide  them  into  super- 
ficial and  deep.  The  superficial  lymphatics  are  situated  imme- 
diately under  the  peritoneum;  the  deep-seated  lymphatics'  form 
several  successive  layers,  which  occupy  different  planes  within  the 
substance  of  the  uterus.  The  lymphatics,  near  the  neck  of  this 
organ,  enter  the  pelvic  and  sacral  lymphatic  glands.  A  certain 
number  of  the  uterine  lymphatics  enters  a  lymphatic  gland, 
situated  at  the  internal  orifice  of  the  obturator  canal.  All  the 
uterine  lymphatics,  excepting  those  near  the  neck  of  that  organ, 
pass  toward  the  sides  and  upper  border  of  the  uterus;  some  run 
within  the  substance  of  the  broad  ligaments,  and  they  all  reach 
the  upper  or  tubal  angles  of  the  viscus.  They  are  joined  by  the 
lymphatics  of  the  ovaries,  broad  ligaments  and  fallopian  tubes, 
and  then  ascend  in  front  of  the  corresponding  ovarian  artery  and 
veins.  Having  arrived  in  front  of  the  lower  part  of  the  kidneys, 
they  incline  toward  the  median  line,  and  enter  the  glands,  which 
are  situated  in  front  of  the  vena  cava  and  aorta ;  without  having 
witnessed  it,  it  is  impossible  to  form  any  idea  of  the  enormous 
size  which  the  uterine  lymphatics  may  acquire  during  pregnancy 
several  of  the  vessels,  when  filled  with  pus,  become  so  dilated,  that 
one  would,  at  first  sight,  believe  that  an  abscess  had  been  formed.'* 


]•:  R  v  E  s . 


00 


NERVES. 

38.  The  nerves  of  the  uterus  are  derived  from  the  renal  and 
hypogastric  plexuses  of  the  sympathetic  system.  The  first  of 
these  nerves  descend  upon  the  spermatic  arteries,  and  are  distri- 
buted like  the  arteries,  both  to  the  ovaries  and  the  uterus:  the 
uterine  branches  being  much  laim-r  than  the  ovarian. 


FIG.  8. — THE  NERVES  OF  THE  UTERUS. 

39.  The  uterine  nerves,  derived  from  the  hypogastric  plexuses, 
are  divided  into  the  ascending   and   descending   branches.     The 
ascending  branches  run  upward  along  the  lateral  borders  of  the 
uterus,  and  terminate  in  its  substance.     The  descending  branches 
furnish  numerous  branches  which  pass  to  the  lower  portion  of  the 
body  of  the  uterus ;  they  then  run  along  the  sides  of  the  vagina 
and  terminate  in  it. 

40.  As  the  hypogastric  plexuses,  from  which  the  uterus  derives 
its  principal  nerves,  are  formed,  not  only  from  the  filaments  of 
the  sympathetic  nerves,  but  also  from  numerous   small  nervous 
filaments  of  the  spinal  nerves,  derived  from  the  sacral  plexuses,  it 
follows  that  the  uterus  is  connected  both  with  the  ganglionic  and 
cerebro-spinal  system,  a  fact  which  accounts  for  the  sympathetic 


54  DISEASES     OF     WOMEN. 

influence  which  it  exercises  during  pregnancy  or  disease,  over  the 
various  functions  of  organic  life,  as  also  on  those  of  the  cerebro- 
spinal  system. 

FALLOPIAN  TUBES. 

41.  The  fallopian  tubes  are  two  ducts,  situated  on  each  side  of 
the  uterus,  and  extending  from  it  to  the  ovaries.     They  arise  from 
the  upper  angles  of  the  uterus,  and  pass  transversely  outward  in 
the  folds    of  the   broad  ligament  for   some   distance,  then   bend 
backward  and  inward,  in  order  to  approach  the  outer  end  of  the 
ovary,  to  which  they  are  attached  by  a   process  of  the  proper 
ovarian  ligament.     The  fallopian  tubes  are  four  or  five  inches  in 
length,  straight  in  the   inner  half  of  their  course,  but  describe 
several    curves    toward  their  outer  extremity.     They  consist  of 
three  coats — an  external  or  peritoneal  coat,  a  middle  or  muscular 
coat,  and  an  internal  lining  of  mucous  membrane.     The  muscular 
coat  consists  of  two  planes  of  fibers ;  the  external  fibers  are  lon- 
gitudinal and  are  a  continuation  of  the  oblique  fasciculi  of  the 
uterus ;  the  internal  fibers  are  circular,  and  are  evidently  contin- 
uous with  the  deep-seated  fasciculi  of  the  uterus. 

42.  The  mucous  membrane  of  the  tubes  is  continuous  with  the 
uterine  mucous  membrane  at  one  extremity,  and  with  the  perito- 
neum at  the  other  extremity  of  the  tube;  thus    presenting  the 
only  instance   in  the    human    body  where  a   mucous    membrane 
becomes  continuous  with  a  serous  membrane,  or  opens  into  a  shut 
sac.      This   mucous   membrane    forms    longitudinal   folds,  which 
render  it  susceptible  of  easy  distention ;    it  frequently  contains 
an  opaque,  white,  milk-like  mucus,  sometimes  puriform,  at  other 
times  transparent,  and  of  greater  or  less  quantity.     The  mucous 
membrane  of  the  fallopian  tubes,  is  more  florid  than  that  of  the 
uterus,  and  the  fimbriae  are  redder  than  the  rest  of  the  tube.    The 
arteries  and  nerves  are  derived  from  the  ovarian.     The  veins  are 
very  numerous,  and  form  frequent  anastomoses  in  the  walls  of  the 
tubes.     When  these  veins  are  distended-  by  a  fine  injection,  the 
tube  is  bowed  upward,  as  if  in  a  state  of  erection,  and  the  fimbriae, 
which  are  likewise  rendered  turgid,  spread  out  upon  the  ovary  so 
that  the  dilated  funnel-shaped  cavity  of  the  tube  is  brought  in 
contact  with  that  organ. 


OVAK1KS.  G-J 

OVARIES. 

43.  The  ovaries  are  two  whitish  bodies  of  a  flattened  oval  form, 
one  of  which  is  situated  on  each  side  of  the  uterus,  in  the  poste- 
rior layer  of  peritoneum  of  the  broad  ligaments,  and  behind  the 
fallopian  tubes.     They  are  retained  in  this  position  by  the  broad 
ligament,  and  by  a  rounded  cord,  consisting  principally  of  muscular 
fibers  derived  from  the  uterus,  called  the  ligament  of  the  ovary. 
By  the  opposite  extremity,  they  are  connected  by  another  and  a 
shorter  ligament  to  the  fimbriated  extremity  of  the  fallopian  tube. 

44.  Their  position  varies  at  different  ages,  and  also  according 
to  the  state  of  the  uterus.     In  the  foetus,  they  are  placed  in  the 
lumbar   regions,  like  the  testicles.     During    pregnancy  they  are 
carried  up  into  the  abdomen  with  the  uterus,  upon  the  sides  of 
which  they  are  applied.     Immediately  after  delivery,  they  occupy 
the   iliac  fossae,  where  they  sometimes  remain  during  the  whole 
period  of  life, — being  retained  there  by  accidental  adhesion.     It 
is  extremely  common  to  find  them  thrown  backward  and  adhering 
to  the  posterior  surface  of  the  uterus. 

45.  The  size  of  these  organs  varies  in  different  subjects,  accord- 
ing to  age,  and  according   to  whether   the    uterus   is   gravid   or 
unimpregnated,  healthy  or  diseased.      The  average  size  of   the 
ovary  is  from  fifteen  to  twenty  lines  in  length,  and  from  eight  to 
twelve  lines  in  thickness.     They  are  relatively  larger  in  the  foetus 
than  in  the  adult ;  they  decrease  in  size  after  birth,  and  increase 
at  the  period  of  puberty — in  old  age  they  become  atrophied. 

46.  Externally,  the    ovaries    receive   an   entire   investment  of 
peritoneum,  which  adheres  so  firmly  to  the  proper  tunic  of  the 
organ,  that  it  can  not  be  detached;  this  is   called   the  indusium. 
Within  this  is  the  proper  coat  of  the  organ — the  tunica  albuginea 
— composed  of  a  dense  fibrous  tissue,  resembling  that  forming  the 
walls  of  the    uterus.     As  the    ovarian    ligament  which    expands 
over  this  organ  and  assists  to  form  this  tunic,  and  other  fasciculi 
of  uterine  muscular  fibers,  traverse  the  broad  ligaments  to  reach 
it,  we    would    be   justified   in   considering  this   a   muscular   coat. 
Within  this  coat  is  a  spongy  and  vascular  tissue,  the  areola  of 
which  seems  to  be  formed  by  very  delicate  prolongations  from  thQ 
external    coat;    in    the    midst  of    this    tissue    the   vesicles    ai\ 


56  DISEASES    OF    WOMEN. 

deposited.  In  virgins  of  mature  age,  it  contains  from  ten  to 
thirty  vesicles,  formed  of  a  delicate  membrane,  filled  with  a  trans- 
parent, coagulable  fluid.  Some  of  these  vesicles  are  situated  so 
near  the  surface  of  the  ovary,  that  they  are  prominent  on  its  sur- 
face; others  are  near  the  center.  They  vary  greatly  in  size, — 
the  largest  being  between  two  and  three  lines  in  diameter,  while 
others  are  not  more  than  half  that  size.  In  addition  to  these 
fully  formed  vesicles,  Dr.  Martin  Barry  has  shown  that  countless 
numbers  of  microscopic  ovisacs  exist  in  the  organ,  and  that  very 
few  of  these  are  perfected  so  as  to  produce  ova. 

47.  After  conception,  a  yellow  spot  is  found  on  one  or  both 
ovaries,  called  the  corpus  luteum.     The  corpus  luteum  is  a  globu- 
lar mass  of  yellow,  spongy  tissue,  traversed  by  white  areolar  bands, 
and  containing  in  its  center  a  small  cavity,  more  or  less  obliter- 
rated,  which  was  originally  occupied  by  the  ovum.     The  interior 
of  the  cavity  is  lined  by  a  puckered  membrane,  the  remains  of 
the  ovisac.      In  corpora  lutea,  the  opening  by  which  the  ovum 
escaped  from  the  ovisac  through  the  capsule  of  the  ovary,  is  dis- 
tinctly visible ;    when  closed,  a  small  cicatrix  may  be  seen  upon 
the  surface  of  the  ovary,  in  the  situation  of  the  opening.     This 
corpus  luteum  generally  continues  until  the  middle  of  pregnancy ;  it 
often  remains  through  that  state,  and  for  some  time  after  delivery, 
but  it  gradually  disappears.     The  cicatrization  continues  through, 
life,  and  gives  rise  to   that  roughened  and  puckered  appeal  ance 
presented  by  the  ovary.     A  similar  body  to  the  above  has  been 
found  in  the  ovaries  of  those  who  have  never  borne  children  ;  they 
are  distinguished  by  their  small  size,  and  by  their  containing  no 
central  cavity :  these  are  called  false  corpora  lutea. 

48.  The   ovaries   are  very  vascular ;    they  receive   numerous 
"branches  of  the  ovarian  or  spermatic  arteries,  which  enter  them 
by  the   lower  margin.     The  veins  accompany  the   arteries  and 
empty  into   the   spermatic   veins.      The  nerves   arise   from   the 
ovarian  plexuses. 

THE  BLADDER  AND  URETHRA. 

49.  It  is  important,  in  obtaining  a  correct  knowledge  of  the 
pelvic  viscera  in  the  female,  that  the  difference  in  the  form  and 


THE     URETHRA.  57 

position  of  these  two  organs  should  be  well  understood.  In  the 
female,  the  bladder  is  generally  larger  than  in  the  male;  and, 
owing  to  the  absence  of  the  prostate  gland,  the  neck  of  it  passes 
down  behind  the  symphysis  pubis,  to  which  it  is  firmly  attached 
by  the  anterior  ligaments.  The  ureters  are  inserted,  and  the 
urethra  commences  in  the  same  part  of  the  bladder  in  both  sexes. 
The  most  important  difference  between  the  male  and  female 
bladder  is  the  relations  of  its  base.  In  the  female,  the  base  of  the 
bladder  rests  upon  the  vagina  below,  and  is  connected  to  it  by  a 
firm  cellular  tissue ;  above  the  vagina  it  is  connected  for  about  a 
half-inch  to  the  cervix  uteri.  As  practical  consequences  of  this 
relation,  I  might  mention  the  ease  by  which  the  bladder  may  be 
examined  through  the  vagina,  or  by  puncturing  it  to  evacuate  the 
urine;  and  of  performing  lithotomy  through  the  same  part;  the 
occurence  of  vesico-vaginal  fistulse,  and  the  frequency  with  which 
carcinoma  of  the  bladder  follows  the  same  affection  of  the  cervix 
uteri. 

THE  URETHRA 

50.  Is  between  one  and  two  inches  in  length,  and  is  closely  con- 
nected to  the  anterior  wall  of  the  vagina,  by  means  of  a  spongy 
cellular  tissue,  which  makes  the  urethra  prominent  in  the  vagina. 
When  the  body  is  in  an  erect  position,  it  is  nearly  horizontal ;  but 
it  is  slightly  curved  with  its  concavity  downward.  The  vesical 
orifice  of  the  female  urethra  is  the  same  as  in  the  male,  only  there 
is  no  prostate  gland.  The  vaginal  orifice,  or  meatus  urinarius,  has 
already  been  described.  The  urethra  is  formed  of  two  coats : 
the  external  coat  consists  of  a  thick  layer  of  circular  muscular 
fibers,  which  seem  to  be  continuous  with  the  fibers  of  the  bladder ; 
some  of  the  longitudinal  fibers  of  that  organ  being  prolonged 
upon  the  outside  of  these.  The  mucous  membrane  of  the  urethra 
is  very  thick,  and  closely  connected  to  the  external  coat,  and  it 
forms  numerous  longitudinal  wrinkles,  as  in  the  male.  In  this 
raucous  membrane  we  find  the  orifices  of  numerous  mucous  folli- 
cles. In  women  who  have  borne  many  children,  the  urethra  is 
shortened,  so  as  not  to  be  more  than  an  inch  or  an  inch  and  a 
quarter  in  length ;  and  the  meatus  urinarius  is  drawn  backward 


58  DISEASES      OF      WOMEN. 

behind  the  pubis,  and  near  its  posterior  face.  The  diameter  of 
the  canal  in  its  natural  state  is  about  a  quarter  of  an  inch,  though 
it  is  capable  of  great  artificial  dilatation. 

51.  In   addition   to    the    organs   described  as  situated  in  the 
cavity  of  the  pelvis,  we  have  to  consider  the  muscles,  ligaments 
and  fasciae  that  surround  and  support  them. 

THE  PERINEUM. 

52.  The  perineum  in  the  female  is  that  space  extending  between 
the  posterior  commissure  of  the  vulva  and  the   anus,  and  upward 
between  the  vagina  and  the    rectum.     This  forms  the  perineal 
triangle ;    its  length  is  about  an  inch  or  an  inch  and  a  quarter 
between  the  vulva  and  anus,  and   it  extends  upward  between  the 
vagina  and  rectum  about  three  inches,  terminating  in  a  point. 
The  perineum  is  composed  of  a  highly  distensible  cellular  tissue, 
which  contains  within  its  substance  but  very  little  adipose  matter. 
Although  it  is  very  distensible,  elongating  under  the  pressure  of 
the  child's  head  during  parturition,  to  three,  four,  or  even  five 
inches,  yet  in  its  natural  state  it  is  very  firm  and  dense ;  and  owing 
to  its  position  in  the  center  of  the  outlet  of  the  pelvis,  and  the 
attachment  of  the  perineal  muscles  and  ligaments  to  it,  it  forms 
the  principal  support  of  all  the  organs  heretofore  described.     The 
perineum  receives  support  in  five  different  directions  ;  from  above, 
by  the  levator  ani,  anteriorly  from  the  triangular  ligament  and 
sphincter  vagina,  posteriorly  from  the  sphincter  ani,  and  laterally 
from  the  transversus  perinei.     In  addition  to  this,  it  is  covered 
externally  by,  and  receives  support  from,  the  common  integument 
and  superficial  fasciae. 

THE  LEVATOR  ANI. 

53.  This  pair  of  muscles  forms  a  hollow  cone,  with  the  base 
directed  upward  toward  the  inlet   of  the   pelvis,  and   the   apex 
downward  toward  the  outlet.     It  arises,  as  in  the  male,  from  the 
inner  surface  of  the  os  pubis ;  from  the  spine  of  the  ischium  and 
from  between  these  points,  its  fibers  run  down,  like  rays  from  a 
circumference  to  a  center,  and  are  inserted  into  the   perineum, 
sphincter  ani,  extremity  of  the  vagina  and  rectum. 


THE     SPHINCTER     ANI.  59 

54.  Uses. — This    muscular   funnel    contains   within    itself  the 
pelvic  organs,  it  antagonizes  the   action   of   the   diaphragm   and 
abdominal  muscles,  and  prevents  these  organs  from  being  forced 
downward  by  their   contraction.     It  elevates  the  fundus  of  the 
bladder  and  the  anus,  and  assists  powerfully  in  the  expulsion  of 
the  urine  and  the  feces.     It  also  elevates  and  supports  the  peri- 
neum   and    the    vagina,    and    those    organs    to    which    they    are 
connected. 

TRIANGULAR  LIGAMENT. 

55.  The  attachments  of  the  triangular  ligament  are  the  same 
in  the  female  that  they  are  in  the  male.     It  is  attached  to  the 
rami  of  the  pubis  and  ischium  of  each  side,  and  firmly  brought 
across  the  triangular  space  formed  by  these  bones,  and  terminates 
posteriorly  in  the  perineum.     It  is  perforated  by  the  urethra  and 
the   vagina,  but  it  is  closely  attached  to  them,  so  as  to  form  a 
strong  support  to  the  anterior  portion  of  the  pelvic  outlet. 

THE  SPHINCTER  VAGINA. 

56.  This  muscle  arises  from  the  sphincter  ani,  at  the  point  of 
its  insertion  into  the  perineum  and  from  the  posterior  side  of  the 
vagina  near  to  this.     From  this  point  it  runs  along  the  sides  of 
the  vagina  near  the  external  orifice,  its  fibers  expanding  over  the 
corpora  cavernosa  vagina.     It  is  inserted  into  the  crura  and  body 
of  the  clitoris. 

57.  Use. — It  contracts  the  orifice  of  the  vagina,  which  it  assists 
to  support,  and  compresses  the  erectile  tissue  of  the  corpora  cav- 
ernosa vagina. 

THE  SPHINCTER  ANI. 

58.  This   muscle   arises,  as  in  the  male,  from  the  superficial 
fascia  around  the  coccyx  and  by  a  fibrous  raphe  from  the  apex  of 
that  bone.     It  is  inserted  into  the  white,  tough  substance  of  the 
perineum. 

59.  Use. — To  close  the  passage  of  the  rectum,  and  by  pulling 
backward  the  perineum,  to  assist  in  contracting  the  orifice  of  tho 
vagina. 


60  DISEASES     OF    WOMEX. 


TRANSVERSUS 

60.  Arises  on  each  side  from  the  tuberosities  of  the  ischium, 
and  is  inserted  into  the  anterior  part  of  the  sphincter  ani,  and 
into  the  perineum.     The  use  of  this  pair  of  muscles  is  to  sustain 
and  keep  the  perineum  in  its  proper  place. 

61.  It  will  be  seen,  by  a  close  examination  of  the   structures 
above  described,  that  they  form  a  perfect  support  to  the  pelvic 
viscera.     And  that  the  perineum  performs  an  important  part  in 
this  support,  as  into  it  are  inserted  all  the  muscles  that  form  the 
floor  of  the  pelvis.     If  this  center  be  weakened  from  any  cause, 
the  result  would  be  obvious,  a  displacement  of  some  of  the  con- 
tained viscera,  the  muscles  of  it  having  partially  lost  one  point  of 
their  attachment. 

THE  PELVIC  FASCIA. 

62.  The  pelvic  fascia  is  attached  to  the  inner  surface  of  the  os 
pubis,  and  along  the  margin  of  the  brim  of  the  pelvis.     From  this 
extensive  origin  it  extends  into  the  pelvic  cavity,  and  divides  into 
two  layers,  the  pelvic  and  obturator. 

63.  The  pelvic  layer,  or  true  pelvic  fascia,  when  traced  down- 
ward from  the  internal  surface  of  the  symphysis  pubis,  is  seen  to 
be  reflected  inward,   to    the  bladder,  forming  the   anterior  true 
ligaments.     It  passes  upon  the  bladder  investing  that  viscus,  to 
the  point  where  it  is  united  to  the  uterus  and  the  vagina.    Tracing 
it  downward  to  the  vagina,  we  find  it  reflected  upon  it,  and  uniting 
it  firmly  to  the  pubic  bones  :  this  forms  the  only  fixed  point  of 
attachment  of  the  vagina.     It  gives  a  complete  investment  to  the 
vagina,  terminating  above  with  its  walls,  and  not  extending  over 
the  uterus,  without  we  should  consider  the  delicate  cellular  tissue 
connecting  the  peritoneum  to  the  uterus  as  its  continuation.     At 
the  sides  of  the  pelvis,  the  pelvic  fascia  passes  off  upon  the  levator 
ani  to  the  bladder,  forming  its  lateral  ligaments.     In  the  posterior 
portion  of  the  pelvis   this  fascia  forms  two  layers  ;  an  anterior 
layer,  which  passes  in  front  of  the  rectum,  and  between  it  and  the 
vagina.     The  posterior  layer  passes  behind  the  rectum,  the  two 
together,  forming  a  complete  investment  for  that  intestine.     It 
will  thus  be  seen,  that  this  fascia  forms  three  complete  sheaths  ; 


BROAD     LI<;  A  MEXTS.  61 

one  anteriorly  for  the  bladder,  a  central  one  for  the  vagina,  and 
one  posterior  for  the  rectum.  The  existence  and  mode  of  distri- 
bution of  this  fascia  adds  greatly  to  the  strength  of  the  floor  of  the 
pelvic  cavity,  which  it  partly  forms,  and  contributes  greatly  to 
retain  the  pelvic  organs  in  their  proper  positions.  It  also  exer- 
cises considerable  influence  in  limiting  and  directing  morbid 
processes,  and  especially  fluid  collections. 

64.  The  obturator  fascia  passes  below,  and  on  the  outside  of 
the  levator  ani,  and  has  the  same  distribution  as  in  the  male. 
Situated  between  the  pelvic  fascia  and  the  walls  of  the  pelvis,  and 
between  it  and  the  muscles  and  the  viscera  that  it  invests,  are 
considerable  quantities  of  cellular  tissue.  This  is  liable  to  in- 
flammation, constituting  pelvic  cellulitis,  which  very  often  termi- 
nates in  suppuration  and  the  formation  of  pelvic  abcesses. 

LIGAMENTS  OP  THE  UTERUS. 

65  The  ligaments  of  the  uterus  are  two  lateral,  or  broad,  and 
two  anterior,  and  two  posterior,  formed  by  duplications  of  the 
peritoneum  ;  and  two  round  ligaments,  which  pass  from  the  an- 
terior surface  of  the  uterus,  through  the  abdominal  rings,  to 
terminate  in  the  cellular  substance  of  the  mons  veneris. 

BROAD  LIGAMENTS. 

66.  The  broad  ligaments  are  formed  of  a  duplication  of  the 
peritoneum,  as  it  passes  off  from  the  sides  of  the  uterus ;  the 
two  layers  become  conjoined  and  pass  to  the  sides  of  the  pelvis. 
Enclosed  between  the  lamina  of  the  broad  ligaments,  we  find  the 
fallopian  tubes  and  ovaries.  This  duplicature  of  the  peritoneum 
is  very  loose, — permitting  the  uterus  to  be  freely  moved  in  any 
direction,  or  even  drawn  to  the  orifice  of  the  vulva,  without  making 
it  tense.  Hence,  the  general  opinion  that  these  ligaments  give 
support  to  the  organ  and  prevent  prolapse,  is  without  foundation. 
The  anterior  and  posterior  folds  of  the  peritoneum,  that  pass  from 
the  uterus  to  the  bladder  in  front,  and  to  the  rectum  behind,  are 
like  the  broad  ligaments — very  loose,  and  can  not  afford  much,  if 
any,  support  to  the  uterus. 


62  DISEASES     OF     WOMEX. 

ROUND  LIGAMENTS. 

67.  The  round  ligaments  are  two  muscular  and  fibrous  cords 
that  arise  from  each  side  of  the  uterus,  at  a  small  distance  before 
md  below  the  origin  of  the  fallopian  tubes,  and  proceed  in  an 

oblique  course  to  the  abdominal  rings.  In  this  course  thev  are 
situated  between  the  layers  of  the  broad  ligaments.  They  pass 
through  the  rings  and  terminate  in  the  cellular  structure  of  the 
mons  veneris.  They  are  accompanied  by  a  small  artery,  by 
several  filaments  of  the  ovarian  plexuses  of  nerves,  and  by  a 
plexus  of  veins.  These  veins  occasionally  become  varicose,  and 
form  a  small  tumor,  resembling  varicocele  in  the  male.  The  laxity 
of  these  ligaments  in  tlie  non-pregnant  condition  of  the  uterus, 
prevents  their  giving  the  uterus  any  support;  it  is  only  during 
pregnancy,  and  when  the  uterus  has  passed  upward  into  the- 
abdominal  cavity,  that  these  ligaments  are  made  tense.  At  this 
time  they  assist  in  retaining  it  in  its  proper  position,  and  draw  it 
forward  against  the  abdominal  parieties. 

68.  As  these  ligaments  do  not  support  the  uterus,  nor  prevent 
its  descent  into  the  lower  portion  of  the  pelvic  cavity,  it  is  im- 
portant to  understand  how  it  is  retained  in  its  normal  position. 
By  referring  to  page  58,  it  will  be  seen  that  the  perineum  and  the 
muscles  attached  to  it  form  a  strong  and  perfect  support,  at  the 
outlet  of  the  pelvis,  to  all  the  pelvic  viscera.     Passing  upward 
from  the  floor  of  the  pelvis,  we  find  the  rectum  posteriorly,  the 
bladder  anteriorly,  and  between  these,  the  vagina.     The  vagina 
has  been  described  as  a  cylinder,  having  a  central  cavity ;  but,  in 
the  healthy  state  of  the  parts,  no  cavity  exists, — the  anterior  and 
posterior  Avails  being  closely  applied  to  each  other, — the  vagina 
forming  a  solid  column  instead  of  a  hollow  tube.     The  vagina  has 
a  firm  support  below,  being  attached  to  the  pubic  bones  by  its 
anterior  wall,  to  the  perineum  posteriorly,  and  between  those  two 
points  it  is  supported  by  the  triangular  ligament  and  the  sphincter 
vagina  muscle.     Upon  the  upper  extremity  of  the  vagina  rests 
the  uterus, — the  two  organs  being  closely  attached  to  each  other 
by  the  insertion  of  the  vaginal  walls  upon  the  cervix  uteri.     So 
long,  therefore,  as  the  vaginal  walls  retain  their  resiliency  and  their 


PATHOLOGY  AXD  DIAGNOSIS.          63 

natural  support  below,  they  form  a  perfect  support  for  the  uterus. 
That  this  forms  its  only  support,  is  fully  proved  in  prolapsus  of  this 
organ ;  for  under  no  circumstances  does  this  occur,  without  there 
is  an  abnormal  laxity  of  the  walls  of  the  vagina,  or  deficiency  in 
the  perineum. 


CHAPTER    II. 


PATHOLOGY    AND    DIAGNOSIS. 

69.  PROBABLY  in  no  other  department  of  medicine  has  there 
been  such  great  advances  made  in  the  last  half  century,  as  in  the 
diagnosis  of  uterine  disease.     The  question  is  often  asked,  why 
are   these   diseases   of   more  frequent  occurrence  now  than  for- 
merly?    We  have  no  reason  to  suppose  that  the  physician  of  the 
present  day  has  to  encounter  any  new  form  of  uterine  disease; 
and  though  these  diseases  are  probably  of  more  frequent  occur- 
rence now,  owing  to  the  present  social  condition  of  women,  than 
they  were  a  century  or  two  ago,  yet  we  have  to  look,  not  to  their 
increased  frequency  for  the  importance  they  have  assumed  of  late 
years,  but  to  the  greater  attention  paid  to  them  now  by  the  pro- 
fession, and  the  improved  means  of  diagnosis. 

70.  The   uterus   and  its   appendages   are  liable   to   the    same 
forms  of  disease  that  attack  similar  tissues  in  other  portions  of  the 
body;  they  are  produced  by  similar  causes,  and  governed  by  the 
same  pathological  laws. 

71.  Thus  the  uterus  and  its  appendages  are  liable  to  excess, 
defect  and  perversion  of  the  functions  of  irritability,  sensibility, 
voluntary  motion,  reflex  action,  sympathy  and  secretion.     To  a 
deficient  supply  of  blood,  determination,  congestion,  inflammation, 
and   all   of   its  results;    to    atrophy,    hypertrophy,  degeneration, 
deposits  and  growths.     These   diseases   may  be  either  primary, 
having  their  origin  in  the  uterine  system,  or  secondary,  arising 
from  some  constitutional  or  general  disease. 

72.  Primary  diseases  of  these  organs  are  of  the  most  frequent 


64  DISEASES     OF     WOMEN. 

occurrence,  from  the  fact,  that  at  each  periodical  return  of  the- 
menstrual  discharge,  there  is  a  determination  of  blood  to  the 
pelvis,  and  a  congestion  of  these  organs,  which  at  this  time  are 
peculiarly  susceptible  to  any  cause  of  disease;  such  as  cold, 
atmospherical  vicissitudes,  etc.  From  the  function  of  reproduc- 
tion, which  imposes  on  these  organs  numerous  changes  in  struc- 
ture and  function,  which  increase  their  tendency  to  morbid  action. 
And  from  other  special  causes,  as  excessive  venereal  indulgence, 
abortions,  the  use  of  emmenagogues  taken  with  criminal  inten- 
tions, etc. 

73.  Disease  of  these  organs  is  secondary,  when  the  local  affec- 
tion is  produced  by  some  constitutional  disease,  the  local  process 
always  resembling,  in  some  degree,  the  constitutional  affection. 

74.  Primary   disease   of   the    uterine    system   may    affect   the 
general  health,  by  the  intensity  of  the  disease;  as  in  inflammation 
of  the  uterus  and  its  appendages  ;  by  loss  of  fluids,  as  in  menorr- 
hagia,  leucorrhea,  ovarian  dropsy,  etc;    by  the  retention  of  an 
excretion   as    in    amenorrhea ;    by    the   generation  of   a    morbid 
material,  which  is   conveyed  into  the  circulation,  as   in   cancer, 
some  cases  of  ulceration,  putrid  substances  in  the  cavity  of  the 
uterus,  etc;  and  lastly,  by  sympathy;  the  diseased  conditions  of 
the  uterine  system  exerting  a  great  and  important  influence,  both 
upon   the  functions   of  organic,  and  those   of  animal  life.     The 
sympathy  existing  between  the  uterus  and  other  organs  supplied 
by  the  sympathetic  nerves,  is  very  marked,  affecting  the  functions 
of  nutrition,  secretion  and  excretion ;  'that  existing  between  the 
uterine  system  and  the  functions  of  animal  life,  is  well  shown  in 
that  protean  malady  hysteria,. 

75.  In  the  diagnosis  of  disease  in  the  uterine  system,  the  phy- 
sician has  two  sets  of  symptoms  to  guide  him.     First,  the  general 
symptoms,  or  the  effects  produced  upon  the  system,  by  the  local 
disease;  and,  Second,  by  the  physical  or  anatomical  signs,  ascer- 
tained by  an  examination  of  the   diseased  parts  and  the  dis- 
charges. 

76.  In  functional  diseases  of  the  uterine  system,  the  physician 
has  to  depend  for  the  most  part  upon  the  general  symptoms  in 
forming  his  diagnosis ;  yet  if  he  be  a  careful  practitioner,  he  will 


PATHOLOGY     AND     DIAGNOSIS.  65 

satisfy  himself  by  examination,  that  no  structural  disease  exists. 
These  symptoms  are  generally  so  well  marked,  and  so  different 
from  those  presented  by  other  affections,  that  there  is  very  little 
danger  of  mistaking  the  disease.  In  structural  disease  the 
general  symptoms  are  important,  so  far  as  they  show  the  effect 
produced  on  the  general  health  by  the  local  disease.  These 
symptoms,  it  is  true,  will  generally  point  out  the  uterine  system 
as  the  seat  of  disease,  but  they  are  never  sufficient  to  point  out 
the  character  of  the  morbid  action. 

Dr.  Simpson  has  well  pointed  out  the  bearing  of  general  symp- 
toms on  any  suspected  case  of  uterine  disease,  and  the  assistance 
to  be  derived  from  them  in  the  formation  of  a  correct  diagnosis, 

O 

as  follows: 

"  First,  the  local  and  functional  state  of  the  uterus  :  so  far  as  it 
is  indicated  by  the  quantity,  character,  periodicity,  etc.,  of  the 
menstrual  and  mucous  secretion  of  the  organ;  by  the  occurrence 
and  non-occurrence  of  morbid  uterine  or  vaginal  discharges,  as 
blood,  serous  fluid,  pus,  etc.;  by  the  existence  or  non-existence  of 
morbid  sensations  in  the  region  of  the  uterus  ;  such  as  different 
modifications  of  pain,  intermittent  or  continuous;  feelings  of  heat, 
weight,  tension,  bearing  down,  etc.;  and  if  the  patient  be  married, 
by  the  reproductive  powers  of  the  organ,  as  shown  by  sterility,  by 
the  occurrence  of  abortions,  etc. 

Secondly,  the  presence  or  absence  of  various  morbid  affections 
of  the  neighboring  viscera,  particularly  of  the  rectum  and  bladder, 
and  of  branches  of  vessels  and  nerves  passing  through  the  pelvis, 
as  indicative  either  of  their  sympathetic  irritation  or  of  their 
mechanical  compression  by  the  enlarged  or  displaced  uterus. 

Thirdly,  the  existence  or  non-existence  of  secondary  local  neu- 
ralgic pains,  in  the  mammas,  along  the  lower  extremities  in  the  loins, 
and  at  points  along  the  course  of  the  spinal  column,  in  the  par- 
ietes  of  the  thorax  or  abdomen  on  either  side,  and  especially 
under  the  left  breast,  along  the  colon,  etc.,  increased  in  their 
intensity  by  any  causes  of  increased  action  in  the  uterus  itself,  by 
the  erect  posture,  menstruation,  etc. 

Fourthly,  the  state  of  the  general  constitution  of  the  patient, 
as  marked  by  various  degrees  of  deviation  from  the  standard  of 


66  DISEASES     OF     WOMEN. 

health,  and  especially  by  the  supervention  of  nervous,  hysterical, 
dyspeptic,  chlorotic,  or  cachetic  symptoms. 

"  The  several  preceding  series  of  morbid  phenomena,  consistsof 
derangements  in  the  vital  actions  of  the  uterus,  or  of  other  parts 
and  organs  secondarily  aifected,  or  of  the  constitution  at  large. 
Up  to  a  late  date  in  the  history  of  uterine  diagnosis,  most  practi- 
tioners remained,  as  some  are  still  satisfied,  with  the  degree  of 
knowledge,  which  is  afforded  by  the  above  sources  of  information. 
No  one,  however,  who  is  practically  acquainted  with  diseases  of 
the  uterus,  can  have  any  hesitation  in  declaring  that  the  symptoms 
derivable  from  these  sources  are  utterly  inadequate,  in  the  general 
routine  of  such  cases,  for  the  purposes  of  correct  diagnosis,  and 
are  constantly  liable  to  lead  into  fallacy  and  error  when  their  indi- 
vidual evidence  is  alone  trusted." 

78.  As  we  have  seen  that,  though  the  general  symptoms   are 
sufficient  in  most  cases  to  locate  the  disease,  but  entirely  insuffi- 
cient to  determine  its  character,  our  main  dependence  in  forming 
a  correct  diagnosis  rests  upon  the  physical  or  anatomical  signs — 
the  result  of  a  careful  examination  of  the  diseased  parts.     There 
are  several  modes  of  examination  proper  to  determine  the  diag- 
nosis of   disease   of  the  uterus  and  its  appendages,  which  might 
be  classified  as  follows :     First,  the  Supra-pubic  examination,  or 
the  examination  of  the  abdomen  by  sight,  touch,  auscultation,  and 
percussion.     Second,  a   manual   or   tactile   examination   by   the 
vagina.      Third,  a  manual  or  tactile  examination  by  the  rectum. 
Fourth,  a  visual  examination  with  the  speculum.     Fifth,  the  use 
of  the  uterine  sound.     Sixth,  dilatation  of  the  os  uteri  so  as  to 
permit  the  examination  of  the  cavity  of  the  uterus  by  the  intro- 
duction of  the  finger.     Seventh,  the  microscopic   and    chemical 
examination  of  the  discharges  from  the  uterus  and  vagina. 

SUPRA-PUBIC  EXAMINATION. 

79.  By  an  examination  above  the  pubis,  we  ascertain  the  exist- 
ence or  non-existence  of  enlargement  of  the  uterus  from  pregnancy, 
tumors,  hypertrophy,  etc.;   secondly,  disease  of  the  ovary,  pro- 
ducing enlargement  of  that  organ ;  thirdly,  the  presence  of  inflam- 
mation by  the  tenderness  on  pressure ;  fourthly,  in  some  degree, 


EXAMINATION     PER     VAGI  NAM.  67 

the  presence  or  absence  of  adhesions  in  ovarian  or  uterine  dis- 
ease. By  auscultation,  whether  or  not  the  enlargement  is  due  tc 
pregnancy,  when  it  has  existed  for  more  than  five  months.  By 
percussion,  the  character  of  the  enlargement,  whether  it  is  solid, 
fluid  or  gaseous.  In  making  this  examination,  the  patient  should 
lie  upon  her  back  with  the  head  and  shoulders  slightly  raised,  and 
the  thighs  semi-flexed  upon  the  abdomen.  The  hypogastrium 
should  then  be  examined  in  every  direction  by  careful  pressure 
with  the  hand,  in  order  to  ascertain  whether  there  is  any  enlarge- 
ment in  that  region  ;  if  there  is,  the  fingers  should  lie  applied  to 
it  so  as  to  ascertain  its  form,  si/e,  consistence,  position  as  regards 
the  median  line,  etc.,  by  trying  to  move  it  from  side  to  side,  we 
may  ascertain  its  degree  of  mobility,  and  the  presence  or  absence 
of  adhesions.  By  pressing  the  hypogastrium  downward  behind 
the  pubis,  the  fundus  uteri  may  frequently  be  detected,  and  if  at 
this  time  the  uterus  be  elevated  by  the  finger  introduced  into  the 
vagina,  or  by  the  use  of  the  uterine  sound,  its  size,  and  condition 
can  be  pretty  accurately  determined.  The  iliac  regions  should  be 
next  examined,  as  the  ovaries  and  fallopian  tubes  are  frequently 
found  there  when  diseased.  When  examining  the  abdomen  by 
percussion,  the  position  of  the  patient  should  be  varied  in  different 
cases,  so  as  to  bring  the  diseased  organ  or  part  in  as  close  relation 
to  the  abdominal  walls  as  possible.  In  auscultation  of  the  abdo- 
men, the  stethoscope  should  be  used,  as  it  is  less  disagreeable  to  the 
patient,  than  an  examination  with  the  ear.  In  the  supra-pubic 
examination  the  results  will  be  greatly  modified  by  the  condition 
of  the  patient,  thus  in  those  of  a  spare  habit,  with  thin  and  lax 
abdominal  wralls,  very  accurate  information  may  be  obtained  on 
all  the  points  above  mentioned ;  but  in  those  of  an  opposite  con- 
dition the  results  will  be  unsatisfactory.  In  making  this  examina- 
tion, it  is  necessary  that  the  bladder  and  large  intestines  should  be 
previously  evacuated. 

EXAMINATION  PER  VAGINAM  BY  THE  TOUCH. 

80.  This  is  one  of  the  most  valuable  means  of  diagnosis  the 
experienced  physician  has  at  hand,  and  yet  one  of  the  least  value 
to  the  inexperienced.  To  make  this  an  available  means  of  diag- 


68  DISEASES     OF     WOMEN. 

nosis,  it  is  necessary  that  the  finger  should  first  be  educated  to 
recognize  the  healthy  state  of  the  parts,  and  then  the  changes 
caused  by  disease.  It  requires  long  practice  and  repeated  trials 
to  accomplish  this,  and  yet  any  one  may  accomplish  it,  if  he  im- 
proves every  opportunity  that  offers.  The  dissecting-rooms  of  our 
colleges  offer  facilities  for  obtaining  this  practical  knowledge,  that 
should  never  be  neglected  by  the  student.  There,  by  repeated 
trials  upon  the  dead  subject,  he  will  not  only  make  himself  famil- 
iar with  the  shape  and  relation  of  the  interior  genital  organs,  but 
he  will  so  educate  the  touch,  that  with  but  a  slight  amount  of  after 
experience,  (comparatively  speaking,)  he  will  be  enabled  to  distin- 
guish the  various  lesions  of  these  organs. 

81.  In  making  an  examination  per  vaginam,  it  is  customary  to 
place  the  patient  on  her  left  side,  near  the  edge  of  the  bed,  with 
her  back  to  the  physician,  the  thighs  drawn  up  toward  the  abdomen 
and  separated,  by  placing  a  pillow  between  the  knees.  The  phy- 
sician should  seat  himself,  with  the  right  hand,  toward  the  patient, 
as  this  will  give  him  the  use  of  this  hand  in  the  examination. 
The  index  finger  should  be  well  oiled,  and  the  hand  then  passed 
under  the  clothes  to  the  vulva :  separating  the  labia,  the  index 
should  be  passed  from  behind,  forward  until  it  enters  the  vagina. 
The  vaginal  walls  should  then  be  carefully  examined,  as  well  as  the 
meatus  urinarius,  course  of  the  urethra,  bladder,  and  rectum,  the 
caliber  of  the  vagina,  its  temperature,  sensibility,  moisture,  the  pres- 
ence or  absence  of  ulceration,  of  morbid  growths,  etc.,  the  thickness 
of  the  perineum,  the  laxity  or  tonicity  of  the  vaginal  walls,  whether 
a  proper  support  is  given  to  adjacent  organs,  etc.  The  finger 
should  then  be  passed  backward  and  upward,  until  it  comes  in 
contact  with  the  os  uteri.  Greater  care  is  necessary  in  examining 
the  vaginal  portion  of  the  cervix  uteri,  from  the  frequency  of  dis- 
ease of  this  part,  and  the  difficulty  of  its  detection.  The  finger 
should  be  passed  around  the  cervix,  in  the  groove  between  it  and 
the  vagina,  and  the  pulp  of  the  finger  should  be  passed  carefully 
over  it,  ascertaining  its  form,  situation,  volume,  density,  tempera- 
ture, sensibility,  the  presence  or  absence  of  ulceration,  morbid  or 
malignant  growths,  etc.  The  os  should  then  be  examined  as  to 
size,  form,  softness,  moisture,  fissures,  cicatrices,  induration,  etc. 


EXAMINATION     BY     THE     RECTUM.  GO 

By  elevating  the  uterus  on  the  tip  of  the  finger,  the  size,  weight, 
and  mobility  of  the  entire  organ  may  he  nearly  ascertained,  as 
•well  as  any  deviation  in  its  position.  After  having  obtained  the 
necessary  information,  the  finger  should  be  carefully  withdrawn, 
to  judge  of  the  character  of  the  discharges. 

82.  The  position  of  the  patient  on  her  side  as  above  described, 
is  the  one  generally  adopted  under  all  circumstances;  yet  Avhere 
the  principal  points  to  be  ascertained   are   the   size,  weight  and 
position   of  the  uterus,   especially  in   any  form  of  prolapse,   the 
examination  will  be  more  satisfactory  if  made  when  the  patient  is 
in  an  upright  position. 

EXAMINATION  BY  THE  RECTUM. 

83.  In  making  a  rectal  examination,  the  position  of  the  patient 
may  be  the  same  as  in  an  examination  by  the  vagina ;  yet  it  is 
much  better  to  have  her  placed  so  that  the  pulp  of  the  finger  may 
be  brought    in    contact  with    the    anterior    wall    of   the    rectum. 
Having  the  index  finger  well  oiled,  it  may  be  readily  passed  into 
the  rectum,  by  steady  and  gentle  pressure  against  the  sphincter ; 
the  finger  should  be  introduced  far  enough  to  distinguish  the  body 
of  the  uterus,  the  other  hand  being  placed  upon  the  hypogastrum, 
pressing    the    bladder    and    uterus    downward     and    toward    the 
rectum.     By  a  rectal  examination  we  are  enabled  to  examine  the 
uterus  in  its  entire  length,  fundus,  body,  and  cervix,  to  determine 
the  degree  of  uterine  enlargement,  to  distinguish  the  character  of 
its  contents,  whether  hard,  heavy  or  incompressible,  or  fluctuating 
and  elastic ;  to  detect  tumors  formed  upon  the  posterior  wall  of 
the  uterus,  or  between  the  uterus  and  the  rectum.     We  may  also 
ascertain  the  existence  of  disease  of  the   ovaries  and  fallopian 
tubes,  while   they  occupy   the   pelvis.     It  is   also   an   important 
means    of  detecting    displacements,   especially   retroversion    and 
anteversion.     In  making  an  examination  by  the  rectum,  the  phy- 
sician should  always  ascertain  whether  it  is  in  a  healthy  condition 
t>r  not. 


70 


DISEASES     OF    TTOMEN. 


EXAMINATION    BY    THE    SPECULUM. 

84.  Though  the  means  already  mentioned  may  suffice,  in  many 
cases,  to  diagnose  the  existing  disease,  yet  in  many  others  they  will 
be  insufficient,  for  while  the  touch  enables  us  to  recognize  structural 
changes  in  the  bulk,  firmness  and  sensibility  in  these  parts,  the 
sight  rectifies  and  perfects  an  erroneous  or  incomplete  opinion, 
by  showing  the   nature   and   limits  of  ulceration,    excoriation  or 
eruption,  the   appearance   of  the   cervix   and   vagina  in   various 
stages  of  disease,  etc.     In  addition  to  its  use  in  forming  a  correct 
diagnosis,   the   speculum   is   an    indispensable  instrument   in  the 
application  of  caustics  and  other  remedies  to  the  diseased  parts. 

85.  Many  varieties  of  the  speculum  have  been  introduced  and 
used  by  the  profession.     Some  of  these   are   very  complicated, 
while  others  are  adapted  for  some  peculiar  condition  of  the  parts, 
and  but  few  of  them  meeting  all  the  requirements  of  the  general 
practitioner.     The  two  that  are  best  adapted  for  general  use,  ful- 
filling  all   the   indications   required   of  the    instrument,   are   the 
cylindrical  glass  speculum  of  Mr.  Ferguson,  and  the  four-bladed 

speculum  of  M.  Ricord.  The  first  of  these  is 
a  stout  glass  cylinder,  about  an  inch  and  a  quarter 
in  diameter,  having  the  inner  extremity  slightly 
beveled,  and  the  outer  extremity  expanded,  the 
vaginal  portion  of  the  tube  being  of  the  same  diam- 
eter throughout ;  this  is  covered  externally  with  a 
brilliant  metallic  coating,  and  this  again  with  a  thin 
layer  of  India  rubber.  The  reflecting  power  of  this 
instrument  is  very  great,  giving  a  clear  view  of  the 
parts  examined.  This  instrument  is  preferable  to 
any  other,  when  caustic  has  to  be  applied  to  the 
cervix  uteri,  as  it  is  not  corroded  by  any  sub- 
stance, always  keeping  clean  and  bright,  while  with 
the  metallic  speculum  great  care  is  necessary  to 

FIG.  9. FERGU-    prevent  the  caustic  from  coming  in  contact  with 

BOX'S  SPECULUM.  the  Blades.  The  speculum  of  M.  Ricord  consists 
of  four  metallic,  semi-cylindrical  blades,  joined  together  at  a  short 
distance  from  the  outer  extremity.  When  closed,  this  instrument 
forms  a  cone,  but  by  pressing  the  handles  together,  after  the 


EXAMINATION     U  Y     TIIK     SPKCULUM. 


71 


instrument  is  introduced,  the  inner  extremity  may  be  expanded  to 
any  extent  desired.  This  speculum  is  so  constructed  that  two  of 
the  blades  may  be  removed,  leaving  a  com- 
mon bivalve  instrument.  This  enables  the 
operator  to  examine  the  condition  of  the  vag- 
inal walls,  and  make  local  applications  to 
them,  through  the  interval  between  the  blades. 
This  speculum  is  furnished  with  an  obturator 
of  polished  wood,  having  a  button  on  its  inner 
extremity  to  receive  the  points  of  the  blades ; 
this  completes  the  cone,  and  facilitates  its 
introduction,  and  obviates  the  pain  which  the 
inequalities  of  the  point  of  the  speculum 
might  otherwise  produce.  When  the  instru- 
ment is  introduced,  and  the  blades  expanded, 
the  obturator  is  disengaged  by  a  spring  at  its 
outer  extremity  which,  acts  against  the  sides 
of  the  speculum. 

86.  There  are  two  positions  in  which  the 
patient  may  be  conveniently  placed  for  the 
introduction  of  the  speculum.  In  the  first 
and  most  common  position,  the  patient  lies  upon  her  back, 
with  the  pelvis  raised,  and  brought  near  the  edge  of  the  bed,  her 
legs  separated,  and  her  feet  resting  on  two  chairs.  The  physician 
standing  or  sitting  in  front  of  the  patient,  introduces  the  fore  and 
middle  fingers  of  his  left  hand  into  the  vagina,  dilates  its  walls, 
and  passes  the  speculum  well  greased  and  warmed,  gently  and 
steadily  between  and  under  them.  After  the  instrument  has  been 
introduced  four  or  five  inches  into  the  vagina,  the  obturator  may 
be  withdrawn,  and  light  thrown  in  at  the  outer  end  of  the  instru- 
ment, unless  the  patient  be  placed  opposite  a  window.  If  the  os 
uteri  is  then  in  view,  the  speculum  should  be  carefully  moved 
in  the  vagina,  until  the  os  is  fairly  placed  in  the  center  of  the 
internal  orifice  of  the  instrument ;  if  it  is  .not  in  view  when 
the  obturator  is  withdrawn,  the  speculum  should  be  carefully 
passed  up  to  it.  After  it  has  been  brought  to  view,  it  should  b 
carefully  examined,  in  regard  to  its  color,  length  and  thickness 


FIG.  10. — RICORD'S 

SPECULUM. 


72  DISEASES      OF      WOMEN. 

the  presence  and  character  of  erosions,  ulceration,  morbid  growths, 
etc.,  the  state  of  the  os  uteri,  its  size,  form,  color,  presence,  and 
character  of  the  secretion,  etc.  In  withdrawing  the  speculum,  the 
vaginal  walls,  course  of  the  urethra,  meatus  urinarius,  and  vulva 

O  7  '  ' 

should  be  examined  with  the  same  care. 

87.  The  second  position  of  the  patient,  for  the  introduction  of 
the  speculum,  is  the  one  adopted  by  Mr.  Simpson ;  he  says,  •'  in 
this  country  great  difficulties  have  been  raised  against  the  more 
general  introduction  of  the  speculum  into  practice,  in  consequence 
of  the.  very  disagreeable  exposure  of  the  person  of  the  patient, 
which  is  usually  considered  necessary  in  its  employment.     In  my 
own  practice,   I    have   laterally   endeavored  to   avoid    this    very 
natural  objection,  by  teaching  myself  to  introduce  and  use  the 
instrument  when  the  patient  wras  placed  on  her  left  side,  in  the 
position  usually  assumed   in  making  a  tactile   examination,  and 
with  the  nates  near  the  edge  of  the  bed.     I  strongly  recommend 
my  professional  brethren  to  follow  this  plan,  as  by  it,  and  with 
attention  to  the  management  of  the  bed-clothes,  I  have  found  that 
the  instrument  can  be  perfectly  employed,  with  little,  or  indeed 
without  any  exposure  of  the  body  of  the  patient.     The  speculum 
is  easily  introduced,  without  the  assistance  of  sight,  and  the  mouth 
of  it  only  requires  to  be  afterward  uncovered,  in  order  to  enable 
us  to  examine  the  cervix  uteri,  and  top  of  the  vagina." 

EXAMINATION  WITH  THE  UTERINE  SOUND. 

88.  The  profession  is  indebted  for  this,  as  well  as  for  many 
other  improvements  in  medicine,  to  Dr.  Simpson  of  Edinburgh. 
Finding  a  great  difficulty  in  detecting  the  existence  and  character 
of  lesions  of  the  body,  fundus  and  cavity  of  the  uterus,  he  pro- 
posed to  obviate  this,  by  an  internal  examination  of  the  uterus, 
by  means  of  the  uterine  sound.     This  instrument  consists  of  a 
solid  stem  of  silver,  or  some  other  metal  capable  of  being  bent  in 
any  manner  required,  and   still   of  sufficient  strength  to  retain 
any  curve  that  is  given  to  it.     This  stem  is  about  nine  inches  in 
length,  one-fifth  of  an  inch  in  diameter,  at  its  thickest  portion 
near  the  handle,  and  one-tenth  of  an  inch  at  its  thinnest  part, 
near  the  other  extremity ;  the  stem  thus  tapers  from  the  handle 


UTERIXE     SOUXD. 


73 


to  the  extremity,  which  terminates  in  a  bulb,  about 
one-eighth  of  an  inch  in  diameter.  The  curvature 
of  the  instrument  is  like  that  of  a  common  male 
catheter,  the  convex  surface  being  marked  by 
grooves,  placed  half  an  inch  from  each  other,  so 
that  the  finger,  introduced  into  the  vagina,  may 
mark  the  length  of  the  uterine  cavity.  The  handle 
of  this  sound  is  flat,  smooth  on  the  convex  surface 
of  the  instrument,  and  roughened  on  its  concave 
surface,  so  as  to  keep  the  operator  constantly 
aware  of  the  direction  of  the  point  of  the  instru- 
ment. 

89.  In    introducing    the    uterine     sound,    the 
patient  may  be  placed  on  her  back,  the  physician 
introduces  the  index  finger  of  the  right  hand  into 
the   vagina,   and   brings   its   extremity   in    contact 
with   the   indentation   formed   in    the  cervix  uteri 
by    the    os    tincge,    so    as    to    act    as    a   guide   to 
the   point  of  the  instrument.     The  sound  is  held 
in  the  left  hand,  and  its  point  slipped  nlong  the 
palmar   surface   of  the   finger  in   the  vagina,  and 
directed  by  it  into  the  uterine  orifice ;  it  generally 
afterward   glides   easily,  under  a  slight  propulsive 
force,  through  the  canal  of  the  cervix,  and  to  the 
fundus  uteri. 

90.  Though  I    have   not    space  for    a   lengthy 
description  of  the  uses  of  this  instrument,  yet  as 
it  comes   highly   recommended,   and    is  likely    to 
prove  -an  important  auxiliary  to  our  other  means 
of  diagnosis,  I  have  given  the  following  observa- 
tions on  its  use,  by  its  originator,  Dr.  Simpson. 

FIG    11 UTER- 

91.  "If,  after  the  bougie  is  introduced  into  the      T^E  gOUND 

uterine   cavity,    we    carry   the    handle     backward 
toward  the  perineum,  the  upper  extremity  of  the  instrument — 
and   consequently    the   fundus    uteri    placed   upon    that    extrem- 
ity— will  be  carried  proportionally  forward  into  the  hypogastric 
region.       One   hand  placed  above   the  pubis  will  now  feel  the 


74  DISEASES    OF    WOMEX. 

fundus  uteri,  with  the  central  and  thinnest  part  only  of  the 
abdominal  parietes  intervening  between  the  fingers  and  the 
surface  of  the  uterus.  Provided  the  Avoman  be  not  of  a  full 
habit,  and  the  abdominal  muscles  sufficiently  relaxed  by  posi- 
tion, we  can  now  pretty  accurately  examine,  with  the  hand 
placed  on  the  hypogastric  region,  the  state  of  the  uterus  as  it  is 
held  forward  on  the  end  of  the  bougie,  and  we  may  always 
make  ourselves  still  more  certain  of  its  condition,  by  retracting 
and  otherwise  moving  the  handle  of  the  instrument,  so  as  to 
bring  the  different  parts  of  the  superior  and  anterior  surface  of 
the  uterine  tumor  under  the  touch  of  the  fingers.  By  a  slight 
turn  of  the  instrument  to  either  side,  the  lateral  surfaces  of  the 
upper  part  of  the  viscus  may,  in  the  same  Avay  be  brought  under 
our  tactile  examination  ;  and  in  spare  subjects,  I  have  occasion- 
ally found  it  possible,  when  the  fundus  was  pushed  against  the 
abdominal  parietes,  to  extend  the  manual  examination  to  some 
distance  along  the  posterior  Avail  of  the  organ.  In  those  cases 
where  it  can  not  be  effected,  the  sound  still  enables  us  to  make  a 
more  perfect  examination  of  this,  the  posterior  part  of  the  uterus, 
than  we  could  othenvise  effect,  by  giving  us  the  power  of  tem- 
porarily depressing  and  reflecting  its  posterior  Avail,  so  that  it 
may  be  felt  by  a  rectal  examination.  The  vaginal  examination  of 
the  loAver  part  of  its  anterior  surface  may,  in  general,  be  more 
complete,  by  a  similar  aid  of  the  instrument. 

92.  "  In  these  different  steps  of  examination,  the  degree  and 
accuracy  of  information  obtained  is  varied  in  different  individuals 
by  the   differences  which   exist   in  the   thickness   of  the   tissues 
placed  between  the  uterine  surface  and  the  fingers ;  but  in  most 
instances  the  presence  of  any  marked  irregularity  in  the  uterine 
structures — such  as  the  presence  of  one  or  more  small  fibrous 
tumors — their  hypertrophic  thickness,  etc.,  may  be  readily  made 
out,    and    under    still    more    favorable    circumstances,   the    exact 
physical  conditions  of  the  organ,  in  relation  to  its  volume  and 
dimensions,  the  morbid  tenderness  of  individual  parts  of  it,  etc.r 
may  be  precisely  determined. 

93.  "  When  we  employ  the  sound,  for  the  purposes  alluded  to 
in  the  preceding  sentences,  namely,  for  enabling  us  to  make  hypo- 


UTERINE     SOUND.  75 

gastric  examinations  of  the  fundus  and  body  of  the  uterus,  the 
instrument,  before  its  introduction,  should  have  its  extremity  bent 
upon  its  stem  at  as  nearly  a  right  angle  as  the  conformation  of 
the  genital  canals  admit,  and,  after  being  introduced,  its  handle 
should  be  well  retracted  toward  the  perineum.  By  attending  to 
these  circumstances,  the  fundus  and  body  of  the  uterus  will  be 
more  easily  and  fully  turned  forward,  and  our  examination  of  it 
greatly  facilitated.  The  same  object  will  also  be  much  promoted 
by  retaining  the  directing  finger  at  the  cervix,  during  the  course 
of  the  examination,  both  to  steady  the  instrument  and  to  serve  as 
a  fulcrum  to  it.  In  that  case  the  handle  may  be  retracted  or 
pushed  forward  to  any  required  degree  by  the  forearm,  while  the 
other  hand  is  employed  in  the  hypogastric  examination. 

94.  "  The  preceding  remarks  apply  to  the  examination  of  the 
fundus  and  body  of  the  uterus,  parts  which — unless  when  much 
enlarged,  or  the  patient  very  thin — are  generally  looked  upon  as 
beyond  the  reach  of  any  physical  diagnosis. 

95.  "  The  physical  states  and  relations  of  the  cervix  uteri,  are 
generally   ascertainable    by   the    finger   alone.     Still,    in  various 
morbid  conditions  of  the  cervix,  our  tactile  examination  of  the 
organ  may  be  much  promoted  by  the    assistance  of  the  bougie 
introduced    into    the    uterine   cavity.     For    instance,  in    chronic 
enlargement,  cauliflower  excresence,  and  other  organic  diseases 
of  that  part,  it  is  sometimes  a  matter  of  moment,  both  as  regards 
our  prognosis   and   our  treatment,  to   involve  or  not  the  lower 
portion  of  the  body  of  the  uterus.     In  several  such  cases,  I  have 
found   much    assistance    in    determining    this    point,    by    gently 
depressing  the  uterus  by  the  bougie  introduced  into  it,  and  having 
the  power  thus  of  examining  the   organ   immediately  above  the 
cervix,  by  compressing   the    structures   of   that   part  between  a 
finger  or  two  in  the  vagina,  and  the  resistant  sound  placed  in  the 
uterine  cavity,  and  consequently  in  the  very  axis  of  the  viscus. 
In  this  way,  each  point  in  the  circumference  of  this  portion  of  the 
organ  may  be  successively  examined. 

96.  "  These  observations  apply  generally  to  such  indications  as 
can  be  made  out  through  the  use  of  the  bougie,  when  the  uterus 


76  DISEASES      OF      WOMEN. 

still  retains  that  freedom  of  motion  we  have  seen  it  possess,  when 
it  is  itself  in  a  healthy  condition,  and  when  there  are  no  obstruc- 
tions or  impediments  to  its  mobility  in  the  surrounding  parts. 
But  there  are  cases  where,  from  the  organ  having  become  more  or 
less  fixed  and  immobile,  no  advantage  can  be  taken  of  those  facil- 
ities which  the  power  of  partially  displacing  it  in  general  allows 
us.  In  these  instances  the  very  circumstance,  however,  of  the 
•mobility  of  the  organ  being  lost,  and  still  more  the  degree  and 
extent  of  its  immobility,  often  materially  assists  in  pointing  out 
the  true  nature  of  the  affection  that  is  present.  Thus  in  scirrhus 
of  the  cervix,  the  early  immobility  of  that  part,  in  consequence 
of  the  morbid  degeneration  invading  the  contiguous  tissues  from 
almost  the  very  commencement  of  the  disease,  is  often  one  of  the 
first  and  best  characteristics  of  that  dreaded  malady.  In  this 
instance,  the  fixed  state  of  the  cervix  of  the  organ  is  detected  by 
the  direct  application  of  the  finger.  In  other  states  of  disease, 
the  cervix  remaining  comparatively  free  and  unaffected,  the  body 
and  fundus  may  be  immobile  from  various  pathological  causes,  as 
from  morbid  adhesions,  the  consequence  of  inflammation  of  its 
peritoneal  surface,  from  the  pressure  of  tumors  or  abscesses,  etc. 
Or,  again,  both  cervix  and  fundus  may  be  immobile  at  the  same 
time,  from  general  carcinoma  of  the  organ,  etc.  In  all  these 
cases  the  immobility  of  the  body  and  fundus,  its  degree,  extent, 
and  seat  can  only  be  discovered  by  the  bougie ;  and  its  use,  along 
with  other  considerations,  may  further  lead  us  to  detect  the 
special  pathological  state  that  may  be  the  cause  of  the  morbid 
attachment  or  fixture  of  these  parts  of  the  organ." 

97.  In  reference  to  the  use  of  the  uterine  sound,  Dr.  Churchill 
makes  the  following  remarks :  "  This  instrument  has  recently  been 
the  subject,  with  others  introduced  by  the  same  distinguished 
author,  of  so  much  obloquy,  that  it  seems  but  just,  that  I  should 
here  express  my  own  opinion  of  its  great  value  in  experienced 
hands ;  at  the  same  time,  I  must  add,  by  way  of  caution,  that  it 
is  one  by  which  much  mischief  may  be  done,  if  it  be  not  used 
ivisety  and  with  great  gentleness.  The  uterus,  even  in  a  state  of 
health,  is  by  no  means  insensible ;  but  in  disease  it  may  become 


EXAMINATION     OF     T  II  K     DISCHARGES.  ti 

very  sensitive.  So  tlmt  the  careful  use  of  the  uterine  sound  may 
be  occasionally  followed  by  severe  pain,  and  its  indiscriminate  and 
rough  use  may  be  highly  injurious." 

DILATATION  OF  THE  Os  UTERI. 

98.  In  some  cases   of  uterine  disease,  it  becomes  necessary  to. 
ascertain  the  condition  of  the  uterine  cavity,  with  greater  preci- 
sion than  can  be  accomplished  by  the  means  heretofore  described. 
This  maybe  done  by  dilating  the  os  and  cervix  uteri  sufficiently  to 
make  an  examination  with  the  finger.     The  os  uteri  can  be  readily 
dilated  by  the  use  of  a  series  of  prepared  conical  sponge  tents, 
each  succeeded  by  a  larger   one,  until  the  necessary  amount  of 
dilatation  is  attained.     These  sponge  tents  may  be  prepared,  by 
taking  a  piece   of  sponge   of  the  requisite  size,  dipping  it  in  a 
strong  solution  of  gum  arabic,  and .  then  compressing  it  into  the 
required  form,  by  wrapping  it  with  whip  cord;  as  soon  as  it  has 
dried,  it  will  retain  the  shape  given  it,  and  the  cord  can  be  re- 
moved; they  should  be  slightly  coated  with  lard,  or  some  unctous 
substance,  to  facilitate   their  introduction.     The  best  mode  of  in- 
troducing these  tents,  is  to  fix  them  on  a  bent  director,  and  pass 
them  up  by  the  finger,  which  has  previously  been  introduced,  to 
the  canal  of   the    cervix ;    the    gum    arabic    is    softened    by  the 
secretion  of  the  parts,  and  the  sponge  expands  to  its  natural  size. 

99.  By  this  means  we  may  be  able  to  detect  the  presence  of 
intra-uterine  polypi,  tumors,  etc. ;  yet  it  should  not  be  employed 
without  the  patient's   life    is  endangered  from   frequent  hemorr- 
hages,  or  some  other  cause,  traceable  to    some   disease   of   the 
cavity  of  the  uterus,  which  may  admit  of  removal. 

EXAMINATION  OF  THE  DISCHARGES. 

100.  In  all  cases  of  disease  of  the  uterus  and  its  appendages, 
the  discharges  from  the  vagina  should  be  carefully  examined  by 
the  physician  himself,  never  trusting  -to  the  description  given  by 
the  patient,  or  by  a  third  person.    The  discharges  from  the  vagina 
may  be  divided  into  four  classes :  discharges  of  blood,  mucus,  pus 
and  serum.     Though  the  result  of  an  examination  of  these  dis- 
charges is  in  no  case  sufficient  for  the  formation  of  a  diagnosis, 


78  DISEASES     OF    AVOMEX. 

yet  in  many  cases  it  will  prove  a  valuable  auxiliary  to  the  other 
modes  of  examination  mentioned. 

101.  Blood.  From  the  period  of  puberty  until  the  female  has  at- 
tained the  age  of  forty  or  fifty  years,  there  is  a  periodical  discharge 
of  blood,  occurring  at  intervals  of  from  twenty-eight  to  thirty  days, 
the  duration  of  the  discharge  being  from  three  to  six  days.     This 
blood,  forming  the  catamenial  discharge,  contains  the  product  of 
the  secretion  of  the  tubular  glands  of  the  uterus,  which  would  be 
appropriate   to   the   formation   of  a  decidual  membrane;    and  is 
mixed  with  the  secretions  of  the  mucous  membrane  of  the  vagina 
and  cervix  uteri.     This  discharge  presents  all  the  characters  of 
blood,  except  the  power  of  coagulating.     The  presence  or  absence 
of  this  discharge  should  be  ascertained  in  all  cases,  as  well  as  the 
regularity  of  its  recurrence,  quantity,  whether    accompanied  by 
pain  or  not,  etc. 

102.  Discharges  of  blood  occurring  at  other  times  than  these, 
may  arise  from  many  different  causes,  as  polypi,  morbid  growths, 
etc. ;  it  may  also  be  in  various  states  of  coagulation,  discolora- 
tion and  decomposition.    The  cause  of  these  discharges  should,  in 
every  case,  be  ascertained  by  the  means  heretofore  named. 

103.  As  the  other  discharges  from  the  vagina  arise  from  causes 
so  various,    a  full   description    of   their  diagnostic   value   would 
increase  this  chapter  to  an  unnecessary  length.     I  would,  there- 
fore, refer  the  reader   to  the  chapter  on   leucorrhea,  where  they 
are  fully  considered. 


INFLAMMATION    OF    THE    VULVA.  79 


CHAPTER     III. 


DISEASES  OF  THE  EXTERNAL  ORGANS  OF  GENERATION. 

SUPERFICIAL  INFLAMMATION  OF  THE  VULVA. 

104.  Any  part  of  the  external   organs  of  generation  may  be 
the  seat  of  inflammation.     This  inflammation  may  be  superficial, 
merely  affecting  the  skin  or  the  mucous  membrane,  or  it  may  be 
very  severe,  affecting  both  the  skin  and  the  sub-cutaneous  tissues. 

.  The  superficial  form  of  this  inflammation  does  not  give  the 
patient  much  uneasiness,  and  it  is  very  rarely  that  a  physician  is 
consulted,  without  the  inflammation  has  produced  an  intolerable 
pruritus,  which  is  much  more  distressing  than  any  pain.  This 
inflammation  may  continue,  producing  ulceration,  and  a  discharge 
of  a  white,  or  yellowish-white  muco-purulent  secretion.  In  a  few 
cases  it  assumes  a  pliagedenic  character,  and  leads  to  a  rapid 
destruction  of  the  adjacent  tissues. 

105.  Appearances. — The  skin  or  mucous  membrane  is  reddened, 
and  slightly  tumefied,  the  mucous  follicles  are  prominent,  some- 
times of  a  pale  color,  at  others  they  present  a  deep  red  or  purple- 
ish  appearance.     If  there   is  ulceration,  the   ulcers   will  be  small 
and  oval,  and  not  more  than  from  one  to  three  lines  in  the  long- 
est diameter.     Or  there  may  be  an  apthous  exudation  covering  a 
greater  or  less  amount  of  the  surface. 

106.  Causes. — This  form  of  inflammation  generally  arises  from 
a  want  of  cleanliness ;  or  from  the  acrid  character  of  the  vaginal 
or  uterine  secretions ;  though  it  may  arise  from  causes  that  would 
produce  inflammation  of  any  other  part  of  the  body. 

107.  Treatment. — In  many  cases  internal  remedies  will  be  im- 
portant, and  they  will  be  selected  b_y  special  indications,  as  in 
other  diseases.     If  there  is  general  feverishness,  Aconite  will   be 
used  as  the  basis  of  the  prescription.     For  burning  pain,  sense 
of  rawness  or  smarting,  give  Rhus.     If  the  patient  complain  of 
extreme  itching,  use  Apis.     If  there  is  pain  in  the  back  or  limbs, 


80  DISEASES    OF    WO  MEN. 

Macrotys.  If  much  irritation  of  the  bladder  and  urethra,  and 
painful  urination,  Eryngiurn.  If  incontinence  of  urine.  Gossypi- 
um.  If  the  patient  has  sensations  of  chilliness  and  cool  extrem- 
ities, Ignatia. 

The  best  local  application  in  the  majority  of  cases  will  be — 
R  Salicylic  Acid,  Borax,  aa.  gr.  xxx.;  water  3viij.  to  sxvi.  In 
some  cases  a  weak  lotion  of  permanganate  of  potash  will  be  bet- 
ter, and  once  in  a  while  Yeratrum  or  Aconite,  if  there  is  great 
tumefaction  and  threatened  suppuration. 

109.  Other  means  have  been  employed  to  relieve  the  pruritus, 
but  if  this  symptom  arises  from  an  inflammation  or  irritation  of 
these  parts,  the  means  we  have  recommended  will  remove  it.     In 
all  cases  strict  attention  to  cleanliness  should  be  required. 

PHLEGMONOUS  INFLAMMATION  OF  THE  VULVA. 

110.  This   form   of  inflammation   involves   both  the   skin,  and 
sub-cutaneous  tissues,  and  occurs  most  commonly  in  the  labia  pu- 
dendi,  though  it  sometimes   attacks  the   mons  veneris.     It  mav 

v 

affect  one  or  both  labia,  and  at  times  gives  rise  to  great  swelling 
of  the  parts. 

The  patient's  attention  is  first  drawn  to  it,  by  uneasiness  in 
standing,  sitting,  or  walking,  for  which  she  can  assign  no  cause ; 
then  follow  pain,  heat,  redness,  and  swelling.  Owing  to  the  char- 
acter of  the  tissues,  the  inflammation  runs  a  rapid  course,  and 
most  generally  terminates  in  suppuration.  When  suppuration 
takes  place,  the  patient  will  complain  of  a  throbbing  pain  in 
the  part,  and  the  pain  upon  motion  or  sitting  will  be  greatly 
increased. 

111.  Causes. — It  arises  in  most  cases  from  some  accident,  a 
fall,  or  blow  of  any  kind  may  give  rise  to  it.     It  has  been  observed 
to  arise  after  a  first  connection,  from  masturbation,  and  after  de- 
livery from  the  pressure  of  the  child's  head,  as  it  passes  through 
the  outlet ;  it  has  also  been  observed  to  arise  without  any  assign- 
able cause,  and  it  sometimes  occurs  during  pregnancy. 

112.  Diagnosis. — This  disease  should  be  carefully  diagnosed 
from  vulvular  enterocele,  for  nothing  could  be  more  dreadful  than 
to  plunge  a  lancet  into  the  intestine  confined  within  the  labiurn  of 


INFLAMMATION    OF      THE      VULVA.  81 

a  patient,  under  the  mistaken  design  of  discharging  a  supposed 
abscess.  This,  however,  can  never  happen,  if  the  differential 
points  are  remembered.  It  may  be  distinguished  from  hernia  by 
the  greater  hardness  of  the  swelling,  and  by  its  circumscribed 
character,  and  more  especially  by  its  not  being  changed  by  cough- 
ing, and  not  being  reducible.  It  may  be  distinguished  from  oede- 
ma of  the  labium  by  its  more  circumscribed  character,  and  darker 
color,  from  tumors  of  the  labium,  by  its  acute  course,  and  by  the 
greater  degree  of  heat,  redness,  and  pain. 

113.  Treatment. — In  the  forming  stages  of  this  inflammation, 
the  treatment  named  in  superficial    inflammation  should  be  em- 
ployed, and  with  the    topical   use  of  Aconite  or  Yeratrum    the 
inflammation  may  be  arrested.     But   it    nun*  be  said  that  in  the 
most  of  cases,  the  physician  will  be  consulted  too  late  to  prevent 
suppuration  ;  as  soon  as  suppuration  has  taken  place,  the  abscess 
should  be  opened  by  means  of  a  longitudinal  incision  on  the  inside 
of  the  labia  externa ;  this  should  be  done  as  soon  as  the  presence 
of  pus  is  ascertained,  in  order  to  prevent  the  burrowing  of  the 
matter  in  the  lax  tissues  of  the  part,  and  its  disposition  to  open  in 
several  places  arid  terminate  in  fistulas.     It  will  be  found  that  the 
tissues  here  do  not  heal  readily,  and,  in  the  most  of  cases,  it  will 
be  necessary  to  make  use  of  stimulating    injections.     The   best 
injection  that  I  have  ever  used  for  this  purpose,  is  a  solution  of 
Sesqui-Carbonate  of  Potassa, — one  drachm  to  four  ounces  of  water 
will  be  found  sufficient  in  the  most  of  cases ;  though  I  have  occa- 
sionally used  a  saturated  solution. 

114.  Abscess  of  the  labia,  which,  from  feelings  of  delicacy  on 
the  part  of  the  patient,  may  have  been  left  without  any  treatment, 
often  terminate  in  fistulas.     These  may  be  very  tortuous, — forming 
a  communication  between  the  rectum  and  the  vagina, — producing 
recto-vaginal  fistula,  or  passing  from  the  rectum  to  the  external 
surface  of  the  labium,  or  from  the  vagina  out  through  the  labium. 
The  two  last  varieties  of  fistula    are  to  be   treated  in  the  same 
manner  that  we  treat  fistula  in  ano  :  by  the  use  of  the  caustics  to 
destroy  the  callous  walls  of  the  fistula,  and  the  use  of  the  ligature. 
See  Howe's  Surgery,  pages  820-1.     The  treatment  of  recto-vagi- 
nal fistula  will  be  given,  when  treating  on  diseases  of  the  vagina, 

6 


82  DISEASES     OF     TFOMEN. 

(EDEMA  OF  THE  LABIA. 

115.  This  is  characterized   by  swelling   of   the   labia,  which 
becomes  tense,  shining,  of  a  rose  color,  transparent,  and  has  but 
little  sensibility  to  the  touch.     When  seen,  it  is  generally  accom- 
panied with  anasarca. 

116.  The  treatment  of  this,  in  addition  to  that  made  use  of 
for  the  general  dropsy,  will  consist  in  steady  compression  of  the 
parts.     If  the  parts  are  very  much  distended,  and  produce  great 
inconvenience,  we  might  procure  the  discharge  of   the  fluid  by 
means  of  small  punctures  made  with  the  point  of  the  lancet. 

COHESION  OP  THE  LABIA. 

117.  This  affection  may  be  either  congenital,  or  it  may  be  the 
result  of  accidental  disorders.     It  is  very  rarely,  in  either  case, 
that  the  cohesion  is  complete ;  a  small  passage  generally  exists 
sufficient  for  the  passage  of  the  urine. 

118.  Sometimes,  but  very  rarely,  the  cohesion  is  complete  at 
birth ;  in  this  case,  the  evacuation  of  urine  would  be  entirely  pre- 
vented, and  death  would  inevitably  ensue,  if  the  necessary  division 
was  not  made.     Cohesion  of  the  labia  may  be  caused  by  acute 
inflammation  of  the  vulva,  either  spontaneous,  or  from  the  effects 
of  a  laborious  labor ;  of  a  burn,  of  a  venereal  affection,  of  a  wound 
or  laceration,  or  any  other  cause  sufficient  to  excite  violent  in- 
flammation of  these  parts. 

119.  Where  the  cohesion  is  partial,  and  occurs  at  the  posterior 
commissure  of  the  vulva,  there  is  always  an  accumulation  of  urine, 
and  other  discharges  at  that  point,  which,  if  suffered  to  remain, 
may  produce  lamentable  effects,  such  as  ulceration  of  the  walls, 
fistulas  of  the  rectum  and  perineum,  etc. 

120.  Treatment. — The  treatment  consists  in  dividing  the  adhe- 
sions  in   the  median  line.     This  may  be  done  with  a  bistoury, 
guided  upon  a  grooved  director ;   the  parts  should  be  carefully 
separated,  breaking  down  the  adhesions  as  much  as  possible  with 
the  fingers,  or  the  director,  as  in  many  instances  the  adhesions 
may  be  broken  up  without  the  aid  of  the  bistoury.     To  prevent 
reunion,  pledgets  of  lint,  spread  with  the   mild  zinc   ointment, 


KNTYSTKI)  TUMORS  OF  THE  LABI  A.        88 

should  be  introduced  between  the  cut  surfaces,  and  continued  until 
the  parts  are  healed. 

IXFLAMMATOKY    (EDEMA. 

121.  (Edema,  sometimes  occurs  with  inflammation  of  the  con- 
tiguous parts.      In   these  cases,  it  presents  all  the  symptoms  of 
phlegmonous  inflammation,  but  which  are  increased  by  the  pre- 
sence of  the  oedema.      With  this  there  is  generally  fever,  a  dry 
and  constricted  state  of  the  skin,  scanty  and  high  colored  urine,  etc. 
Here  the  special  sedatives,  with    such    other  remedies  as  may  be 
indicated  (usually  Apocymim)  will  give  the  best  results.    In  many 
cases,  much  relief  may  be  given   by  the  employment  of  a  brisk 
hydragogue    carthartic,  as  the  compound    powder   of   Jalap   and 
Senna  with  Cream  of  Tartar.     In  addition  to  this,  the  same  local 
treatment   should   be   employed  that  we    have   recommended   for 
inflammation  of  the  labia. 

EXCYSTED  TUMORS  OF  THE  LABIA. 

122.  Encysted  tumors  of  the  labia  are  of  more  frequent  oc- 
currence than  any  other  variety.     They  are  of  various  sizes  ;  some 
not  being  larger  than  a  partridge's  egg,  while  others  have  been 
reported  as  large  or  larger  than  a  goose  egg.     These  tumors  are 
generally  circumscribed  and  tense, — forming  a  round  or  oval  pro- 
jection  from    the  vulva, — and  they   are    often   semi-transparent. 
The  contents  of  the  cyst  are  very  various  ;  sometimes  a  yellow 
serum,  at  others,  a  glairy,   viscid  fluid,  a  dark-colored  puriform 
matter,  or  a  semi-solid,  lardaceous  matter ;  the  cavity  is  always 
lined  with  a  distinct  secreting  membrane — the  proper  cyst  wall. 

123.  These  tumors,  when  small,  may  continue  for  years,  and 
give  the  patient  but  very  little  uneasiness ;  in  other  cases,  they 
may  augment  rapidly  in  volume,  and  give  the  patient  much  un- 
easiness, by  their   size  and   the   tension   of   the   parts,  which  is 
generally  aggravated  by  motion.     They  very  rarely  produce  any 
pain ;  though,  in  some  cases,  they  have  produced,  by  their  pre- 
sence and  weight,  irritation  of  the  adjacent  organs.     Dr.  Ashwell 
states  that  "  the  cyst,  owing  to  the  injudicious  handling,  sometimes 
inflames,  and  its  contents  are  converted  into  a  semi-purulent,  thin 


84  DISEASES      OF      WOMEN. 

matter,  tinged  with  blood.  A  great  deal  of  irritation  is  established 
in  the  vulva,  and  the  feeling  of  simple  enlargement  and  fullness, 
which  at  first  is  alone  felt  by  the  patient,  is  now  aggravated  by 
heat  and  shooting  pains,  and  tenderness  in  walking  or  sitting 
down.  In  some  rare  cases,  ulceration  has  taken  place  in  them, 
and  a  very  unpleasant  sore  has  been  formed.''  On  making  an 
examination,  the  labium  will  be  found  enlarged,  and  the  tumor 
may  be,  in  general,  defined  beneath  the  skin;  it  is  less  identified 
with  the  surrounding  parts  than  a  phlegmonous  abscess ;  it  is  not 
tender  on  pressure,  nor  is  there  any  change  of  color. 

124.  Diagnosis. — This  tumor  may  be  distinguished  from  phleg- 
monous inflammation  from  its  slow  growth,  and  from  the  absence 
of  the  characteristic   symptoms  of  inflammation,  pain,  heat,  and 
redness;  it  may  be   distinguished  from  oedema  of  the  labia  by  its 
circumscribed  form,  by  its  being  confined  to  one  labium,  and  by  its 
slow  growth. 

125.  The  diagnosis    between    these   tumors  and  inguinal    and 
pudendal  hernia,  is  often  a  matter  of  much  greater  difficulty ;  for 
both  diseases  may  occupy  the  same  position,  and  both  have  the 
same  soft  and  elastic  feeling.     The  distinguishing  points  between 
the  two  are,  that  the  cyst  does  not  swell  and  distend  while  cough- 
ing, and  it  can  not   be  returned  into  the  abdomen ;    if,  however, 
there  is  any  doubt  on  this  point,  the  exploring  needle  should  be 
used  before  making  an  incision  into  the  tumor. 

126.  Treatment. — To  remove  these  tumors,  it  is  necessary  that 
the  cyst  should  be  emptied,  and  the  cyst-wall  entirely  destroyed. 
If  the  cyst-wall  is  not  destroyed,  it  will  continue  to  secrete  fluid, 
and  keep  up  the  disease  indefinitely.     It  has  been  recommended 
by  some  authors  to  dissect  out  the  entire  cyst :  this  would  no  doubt 
entirely  eradicate  the  disease  ;  but  it  is  a  painful  and  difficult  ope- 
ration, and,  if  the  tumor  is  large,  it  is  not  unattended  with  danger. 
The  surest  and  best  method  will  be  to  make  a  sufficiently  large 
incision  into  the  tumor  to  evacuate  the  fluid,  and  then  inject  the 
cavity  with    a    saturated    solution    of    the    Sesqui-Carbonate    of 
Potassa.    This  injection  will  produce  considerable  pain  for  the  first 
ten  or  fifteen  minutes,  but  it  is  not  followed  by  a  high  degree  of 
inflammation.    It  changes  the  character  of  the  secreting  membrane, 


KXCYSTEI)     TUMORS     OF     THE     LABIA.  85 

excites  adhesive  inflammation  of  its  walls,  and  thereby  effectually 
destroys  the  reproductive  power  of  the  cyst.  This  injection  can 
be  repeated  as  often  as  may  be  necessary,  until  the  parts  are 
healed. 

127.  Oozing     Tumor    of  ilie    Lab  in. — This    disease    was    first 
described  by  Sir  Charles  Clark.     It  arises  in  one  or  both  labia, 
and  sometimes  extends  to  the  mons  veneris.     He  states  that  this 
tumor  is  sometimes  so  large   as  to   leave   scarcely  any  part  of  the 
labia  free  from  it;  it  seldom  projects  far  above   the  plane  of  the 
surrounding  skin,  often  not  more  than   a  line  or  two,  and  rarely 
more  than  one-third  of  an  inch. 

128.  The  color  of  the  tumor  varies  little  from  that  of  the  cuti- 
cle of  the  neighboring  parts  ;   and  a  projection  very  much  resem- 
bling it,  might  be  made  by  the  firm  application  of  a  piece  of  fine 
netting  to  the  oedematous  part,  during  a  few  seconds,  the  surface 
being   unequal,  consisting  of  irregular  depressions  and  eminences, 
from  the   former    of  which   the    fluid   oozes.      In   the    immediate 
neighborhood  of  the  tumor,  oedema  is  occasionally  met  with,  but 
the  tumor  is  not  itself  eedematous  ;  soon  after  the  surface  of  the 
tumor   has  been   wiped  quite  dry,  a  watery  fluid  begins  to   ooze 
from  it,  and  forms  drops,  which  having  become  large,  at  length  run 
off,  and  keep  the  surrounding  parts  in  a  constant  state  of  humidity. 

129.  This  disease  having  once  begun,  continues  to  enlarge,  and 
insulated  patches  of  it  appear  in  other  neighboring  parts  ;  and 
after  a  time  they  will   be  found  to  run  together,  forming   a  single 
tumor.     At  first   it  does  not  produce   much  inconvenience,  but  as 
the  tumor  enlarges,  the  fluid  increases  in  quantity,  and  by  its  con- 
stant passage  over  the  neighboring  parts,  they  become  excoriated 
and  irritable,  and  occasion  much  local  suffering.     Hence,  smarting 
and   shooting  pains   about  the  inner  side  of  the   labium,  with  a 
general  sense  of  heat  in  the  external  organs,  and  pain  and  heat 
in  passing  water,  become  troublesome  symptoms. 

130.  Treatment. — As  these  tumors  are  of  very  rare  occurrence, 
being  seldom  met  with  in  general  practice,  we  have  no  means  of 
knowing  what  effects  would  be  produced  upon  them  by  those  rem- 
edies  used  by  Eclectics  for  analagous   affections.     Dr.  Ashwell 
states,  that  this  condition  of  the  labium  is  not  much  under  the 


86  DISEASES     OF     WOMEN. 

control  of  remedies.  Contrivances  to  imbibe  the  fluid  as  it  exudes, 
and  prevent  its  running  over  the  adjacent  parts,  are  important. 
Lint,  moistened  with  cold  water,  or  a  weak  solution  of  alum  or 
sulphate  of  zinc,  covered  with  oiled-silk  and  supported  by  a  ban- 
dage, will  be  found  to  give  relief.  In  addition  to  these  local  means, 
great  benefit  will  be  derived  from  attention  to  the  general  health, 
which  is  always  more  or  less  impaired.  A  nutritious  diet,  with  a 
moderate  quantity  of  stimulants,  in  conjunction  with  the  use  of 
chalybeates  and  the  vegetable  tonics,  will  reestablish  the  general 
health  of  the  patient,  lessen  the  local  disease,  and  prepare  the 
patient  for  a  radical  cure. 

Sir  C.  Clark  operated  once  for  the  removal  of  this  tumor, 
by  excision  of  the  labium.  More  recently  the  operation  was 
performed  by  Mr.  Rump.  Both  of  these  cases  were  successful. 
Churchill  thus  describes  the  operation  performed  by  this  last 
Surgeon:  "The  patient  having  been  secured  in  the  lithotomy 
position,  the  tumor  was  drawn  forward  from  the  pubis,  and  its 
base  transfixed  near  the  clitoris,  and  on  a  level  with  the  nymphse, 
•with  a  straight  bistoury,  which  was  then  carried  downward  to  the 
fourchette,  and  brought  out.  The  knife  was  reiipplied,  and 
directed  upward  toward  the  mons  veneris.  By  this  means  the 
labium  was  speedily  removed.  The  round  ligaments  were  laid 
bare,  and  three  small  arterial  branches  bled,  but  did  not  require  a 
ligature.  The  edges  of  the  long  elliptical  wound  were  brought 
together  by  interrupted  sutures  and  cold  water-dressing  applied." 
This  appears  to  be  the  only  means  of  effecting  a  radical  cure  of 

the  disease. 

•  VARICES  OF  THE  LABIA. 

134.  According  to  Colombat,  varices  of  the  labia  constitute  a 
rather  rare  affection.  They  may  be  distinguished  from  other 
affections  of  the  labia,  by  the  following  characters :  The  dilated 
veins  form  beneath  the  skin  on  one,  and  the  mucous  membrane  on 
the  opposite  side  of  the  labium ;  certain  lumps,  which  are  more  or 
less  protuberant  as  they  are  of  older  or  more  recent  date.  The 
tumors  are  indolent  upon  pressure,  of  a  bluish  color,  and  of 
consistence  so  soft  that  they  disappear  under  pressure,  to  reappear 
again,  as  soon  as  the  weight  is  taken  off.  In  some  instances  these 


YARICKS     OF     THK     LABIA.  87 

tumors  become  irritated  and  then  inflame,  when  they  become  the 
seats  of  fungus  ulcers  difficult  to  heal.  This  affection  sometimes 
becomes  very  distressing  in  consequence  of  the  pruritus  with 
which  it  is  accompanied. 

135.  Causes. — These  are  various  ;  it  may  arise  from  too  fre- 
quent coitus,  from  pregnancy  too  often  repeated,  from  difficult 
labors,  especially  where  instruments  have  to  be  used,  and  from 
any  cause  which  obstructs  the  free  passage  of  the  venous  blood 
through  the  pelvis. 

130.  Treatment. — If  the  cause  producing  the  varicose  condi- 
tion of  the  vulvar  veins  can  be  ascertained,  our  efforts  should  be 
directed  to  its  removal,  for  very  frequently  the  varix  disappears 
spontaneously,  when  the  cause  that  produced  it  ceases  to  act.  In 
many  cases  the  internal  use  of  Pond's  Extract  of  Hamamelis,  in 
doses  of  ten  to  twenty  drops  four  times  a  day,  and  its  local  use, 
will  prove  of  great  benefit.  The  parts  should  be  properly  sup- 
ported and  kept  free  from  discharges. 

137.  With  these  applications,  steady  compression  of  the  parts 
should  be  maintained.  To  relieve  the  pruritus,  which  often  accom- 
panies this  affection,  nothing  will  be  better  than  Meigs'  lotion  of 
borax  and  morphia. 

R    Sodse  Borat  gss. 

Morphia  Sulphas  gr.  vj. 

Aq.  Rosae  Distillat.  %iv. 

M.  F.  Misturae. 

If  the  varices  have  terminated  in  the  fungus  ulcers  above 
spoken  of,  it  will  be  necessary  to  make  free  use  of  the  sesqui-car- 
bonate  of  potassa,  until  the  ulcer  assumes  a  healthy  appearance. 
The  best  means  of  applying  this  is  to  saturate  a  small  portion  of 
cotton  with  the  potassa,  as  strong  as  it  can  be  dissolved,  and  then 
sprinkling  on  it  as  much  of  the  dry  powder  as  will  adhere.  This 
should  be  carefully  placed  in  the  ulcer,  protecting  the  adjacent 
parts  with  the  dry  cotton.  As  soon  as  the  fungus  growth  has 
been  destroyed,  I  would  recommend  the  use  of  the  following  so- 
lution until  the  ulcers  are  entirely  healed  : 
R  Salicylic  Acid, 

Borax,  aa.  3J- 

Water,  gxij.        M. 


88  DISEASES      OF     WOMEX. 

THROMBUS  OR  SANGUINEOUS  TUMOR  OF  THE  LABIA. 

138.  This  consists  in  an  extravasation  of  blood  into  the  cellular 
tissue  of  the  labia,  and  results  from  a  rupture  of  some  vessels  of 
the  parts,  most  generally  of  the  veins  ;  and  according  to  some 
authors,  of  those  varicose  veins  which  are  not  unfrequently  found 
about  the  origin  of  the  vagina  and  the  labia.     These  tumors  have 
always,  so  far  as  I  have  seen  cases  reported,  occurred  as  a  com- 
plication of  parturition,  thus  it  may  occur  previous  to  the  delivery 
of  the  child,  during  labor,  but  much  more  frequently  immediately 
after  its  termination. 

139.  This  effusion  of  blood  may  effect   one  or  both  labia;  it 
may  also    extend  upward  into  the  pelvis,   or  downward  to    the 
perineum ;  the  tumor  thus  formed  is  of  a  variable  size,  owing  to 
the  distensibility  of  the  tissues,  sometimes  becoming  as  large  as 
a  child's  head  ;  it  is  very  irregular  and  of  a  livid  or  black  color. 
As  the  distension  of  the  parts  increases,  it  will  become  intensely 
painful ;  the  patient  lies  on  her  back,  with  the  thighs  drawn  up 
and  widely  separated.     She  is  scarcely  able  to  move,  and  can  not 
even   support  the  weight  of  the  bed-clothes.     Dr.  Dewees  states, 
that  should  the  parts  not  give  way,  the  pain  arising  from  disten- 
sion is  unceasing  and  truly  agonizing;  fever  of  a  very  active  kind 
is  kindled ;    delirium   sometimes    attends,  and   the    female's   life 
becomes  severely  threatened.     Her  sufferings  are  also  augmented 
by  retention  of  urine,  as  its  passage  is  prevented  by  the  tumor 
pressing  firmly    against   the    meatus    urinarius    of   the    urethra. 
These  tumors  have  occured,  both  during  protracted  and  natural 
labors,  but  most  frequently  during  the  latter ;  so  that  there    is 
nothing  in  the  character  of  the  labor  that  would  cause  the  practi- 
tioner to  suspect  its  occurrence.    .In  some  cases  its  progress  is 
very  rapid,  the  quantity  of  blood    effused  being  so  great  as  to 
produce  syncope  ;  in  other  cases,  the  swollen  mucous  membrane 
gives  way  in  a  short  time,  giving  rise  to  dangerous  hemorrhage 
If,  however,  the  labor  is  concluded  without  a  rupture  of  the  tumoi 
after  the  lapse  of  a  short  time,  the  mucous  membrane  is  observed 
to  vesicate,  and  then  to  become  gangrenous,  when  it  yields  to  the 
pressure,  and  the  contents  of  the  tumor  are  discharged.     In  this 


THROMBUS     OF     THE     LAB]  A.  89 

last   case    the    blood  is   always   found   more    or  less    coagulated, 
forming  clots,  and  the  subsequent  hemorrhage  is  not  so  great. 

140.  There  is  no  other  affection   of  these  parts  with  which  this 
tumor  could  he  confounded,  if  proper  care  he  used  in  its  diagnosis: 
thus  it  may  he  diagnosed  from  liernia  by  the  rapidity  of  its  forma- 
tion, by  its  irregular  form,  the  entire  fluidity  of  its  contents,  its 
color,  and  by  its  riot  being  reduceable,  and  not  being  changed  by 
coughing.     From  inversion   of  the  uterus,  by  the  position  of  the 
tumor,  which  occupies  the  side  or  sides  of  the  vagina  ;   while  the 
canal  is  free,  the  uterus  and  bladder  being  felt  in   their  normal 
position. 

141.  Treatment. — The   treatment   of  this   difficulty   will   vary, 
according  to   whether  it  arises   previous   to,  or  during  labor,  or 
after  the  birth  of  the  child.     If  it  arises  during  labor,  the  tumor 
may  become  so  large  as  to  interfere  with  the  birth  of  the  child. 
If  this  be  the  case,  we  have  to  take  our  choice  between  leaving 
the  case  to  the  natural   powers  of  the  system,  or  of  making  an 
incision  into  the  tumor  and  discharging  the  fluid.     The  clanger  in 
trusting  the  case  to  nature  is,  that  if  the  tumor  be  large  it  will 
either  prevent  the   passage  of  the  head,  or  give  way  before  it, 
giving  rise  to  serious  hemorrhage.     It  is,  therefore,  recommended 
in  this  case,  to  make  a  free  incision  on  the  mucous  surface  of  the 
swelling,  and  allow  the  effused  blood  to  escape.     Should   there  be 
serious  hemorrhage  after  the  incision,  we  may  check  it,  by  steady 
compression  over  the  part,  and  the   application  of  ice.     If,  how- 
ever, the  enlargement  is  not  so  great  as  to  offer  a  serious  obstruc- 
tion to  delivery,  it  would  be  better  to  wait,  and  not  lay  open  the 
tumor,  (if  the  pain  be   bearable,)  until  the  lapse  of  a  few  hours, 
for  in  this  time,  coagulation  of  the  blood  will  take  place,  and  the 
orifices  of  the  ruptured  vessels  will  be  somewhat  occluded ;   yet 
inasmuch  as  an  incised  wound  heals  more  readily  than  one  that 
results  from  sloughing  of  the  tissues,  the  incision  should  be  made 
at  least  as  soon  as  any  appearance  of  vesication  is  discovered.     It 
would  be  well  not  to  remove  all  the  coagula  at  once,  as  it  might 
produce  a  fresh  return  of  hemorrhage. 

142.  If  this  effusion   occurs   either  before  or  after  labor,  and 
•the  tumor  formed  is  but  of  small  size,  we  might  attempt  to  pro- 


SO  DISEASES     OF     WOMEX. 

duce  resolution.  For  this  purpose,  there  is  nothing  better  than 
the  Tincture  of  Arnica  Montana  (3'j  to  Svj  of  water)  applied  to 
the  parts  cold,  by  means  of  cloths  saturated  with  the  fluid.  This 
will  also  be  found  to  be  one  of  the  best  applications  that  can  be 
made  to  the  parts,  after  the  fluid  has  been  discharged,  without 
there  is  considerable  fetor,-  with  a  tendency  of  the  parts  to  slough ; 
when  it  would  be  well  to  alternate  this  with  the  Liquor  Sodae 
Chlorinates,  Sj  to  3x  of  water.  It  is  always  necessary  to  sustain 
the  strength  of  the  patient  by  appropriate  stimulants  and  tonics, 
nourishing  diet,  etc.  The  bowels  should  be  kept  regular,  the 
patient  quiet,  and  all  untoward  symptoms  met  by  appropriate 
treatment. 

VENOUS  HEMORRHAGE  FROM  THE  VULVA. 

143.  In  this  connection  it  may  be  well  to  mention,  that  cases 
of  venous  hemorrhage  from  the  vulva,  of  a  dangerous  character, 
have  been  reported  by  several  authors ;  some  of  which  have  been 
the  subject  of  legal  investigation,  in  consequence  of  the  death  of 
the  female,  and  the  supposition  that  the  hemorrhage  arose  from  a 
wound  made  with  criminal  intent. 

144.  Dr.  Simpson  relates  a  case  of  this  kind,  as  reported  to 
him  by  Dr.  Kyle  of  Dundee ;  who  was  called  to  see  the  woman, 
but  did  not  arrive  until  after  she  had  expired.     No  grounds  could 
be  discovered  for  any  suspicion  that  the  woman  had  received  a 
wound.     She  was  in  the  lower  rank  of  life,  but  respectable,  and 
living  on  good  terms  with  her  husband  and  neighbors.      She  had 
been  straining  at  the  night-stool,  when  the  hemorrhage  came  on. 
A  large  quantity  of  blood  was  found  about  her  person ;  it  had 
flowed  into  the  genital  organs.     On  making  the  autopsy,  Dr.  Kyle 
paid  particular  attention  to  the  state  of  the  uterus,  which  was 
fully  expanded  in  pregnancy;  but  no  effused  blood  was  discovered 
in  or  around  it.     On  examining  the  vagina  and  vulva,  Dr.  Kyle 
found  a  recent  aperture  in  one  labium,  which,  on  further  dissec- 
tion, he  traced  into  a  large  vein. 

145.  Dr.  Simpson  also  alludes  to  the  anatomical  fact,  that  there 
was,  at  the  root  of  each  labium,  a   plexus  of  very  large  veins, 
which  extended  some  way  into  the  vagina.     One  of  these  veins. 


VENOUS     HEMORRHAGE.  91 

probably  in  a  varicose  state,  luul  burst  in  tliis  instance.  Possibly 
the  coat  of  the  vein  was  thickened,  as  well  as  dilated,  and  conse- 
quently it  would  not  collapse,  as  veins  usually  do,  but  remained 
open,  like  an  clastic  artery. 

140.  He  further  states,  that  the  case  seemed  to  him  particularly 
interesting  and  important,  in  relation  to  medical  jurisprudence. 
A  number  of  criminal  trials  had  taken  place  in  Scotland  within 
the  memory  of  the  members,  in  consequence  of  women,  generally 
but  not  always  pregnant,  having  died  from  hemorrhage  from  the 
pudenda,  similar  to  the  above.  In  most  or  all  of  these  cases,  it 
had  been  averred,  that  the  wound  had  been  inflicted  with  criminal 
intent,  by  the  husband  or  others.  Dr.  Watson  has  recorded  two 
or  three  such  cases ;  Dr.  Seller  has  recorded  others ;  and  Dr.  S. 
himself  had  seen  the  examination  of  the  body  in  two  criminal 
cases  of  this  kind.  In  both  the  women  bled  to  death  from  very 
small  wounds  of  the  pudenda.  He  was  not  aware  that  in  any  of 
the  five  or  six  cases  of  late  years,  tried  before  the  Scottish  courts, 
the  plea  of  the  apparent  wound  being  a  spontaneous  rupture  had 
been  adduced.  But  such  a  case  as  this,  that  had  lately  occurred 
at  Dundee,  had  evidently  important  bearings  on  the  value  of  such 
a  plea.  (Obstetric  Memoirs,  Vol.  1,  p.  277.) 

147.  Another  case  of  this  kind  is  reported  by  Dr.  Thompson 
and  Dr.  Martin  Barry ;  though  in  this  case  the  woman  was  not 
pregnant.  The  patient,  a  married  woman,  nineteen  years  of  age, 
had  already  borne  two  children,  the  last  only  six  weeks  before  the 
accident.  Dr.  Barry  saw  her  eight  hours  after  the  bleeding  had 
commenced.  He  found  her  in  a  very  weak  and  anemic  condition, 
the  skin  blanched,  the  lower  extremities  already  becoming  cold ; 
the  countenance  very  anxious;  much  jactitation ;  pulse  rapid,  and 
extremely  weak  and  fluttering.  The  vagina  was  immediately 
plugged;  cold  cloths  were  applied  to  the  abdomen  and  vulva,  and 
stimulants  and  astringents  administered  by  the  mouth.  After 
some  hours  the  patient  had  recovered  to  such  an  extent  as  to 
admit  of  her  being  turned  upon  her  left  side ;  and  on  examination 
a  wound  was  discovered,  large  enough  to  admit  the  finger,  to  the 
depth  of  about  half  an  inch,  in  the  anterior  wall  of  the  vagina,  at 
the  union  of  its  upper  with  its  middle  third.  On  the  following 


92  DISEASES     OF    WOMEN. 

day,  Dr.  Thompson,  who  had  been  called  in  by  Dr.  Barry,  found 
her  in  an  extremely  depressed  state,  but  subsequently  she  recov- 
ered perfectly.  This  woman's  husband,  a  cattle-drover,  had  been 
long  absent  from  home,  and  on  the  evening  of  the  accident,  his 
visit  lasted  only  half  an  hour,  during  which  time  he  had  been 
alone  with  his  wife.  Immediately  after  he  had  left  her,  the  bleed- 
ing commenced.  Had  death  actually  occurred  in  this  case,  tin 
existence  of  the  wound  might  have  given  rise  to  suspicion  o' 
criminal  violence  having  been  resorted  to. 

WARTY  TUMORS  OF  THE  VULVA. 

148.  These  excresences  may  be  developed  upon  any  part  of  the 
external    genitals,   and  are    sometimes    observed   in   the   vagina. 
They  may  arise  at  any  age,  having  been  observed  in  children  not 
more  than  three  years  old.     These  tumors  may  be  single   or  in 
groups ;  their  size  varies  from  that  of  a  pea  to  that  of  a  hen's  egg  ; 
they  are  generally  prediculated,  but  sometimes  the  base  of  the 
tumor  is   the   largest   part ;   there   is  scarcely  any  difference    in 
color  between  these  vegetations  and  the  adjacent  parts. 

149.  Symptoms. — These  tumors  may  be  present  for  some  time, 
without  giving  the  patient   any  uneasiness,  but  most   commonly 
they  produce  considerable  irritation,  giving  rise  to  a  discharge  of 
mucus  more  or  less  profuse,  and  which  resists   all  means  usually 
•employed  for  its   relief.     If  the  tumors  be  large,  they  produce 
more  or  less  inconvenience  in  walking,  sitting,  etc.     Examination 
is  the  only  means  by  which  they  can  be  detected. 

150.  Causes. — These  excresences  sometimes  arise  from  a  want 
of  personal  cleanliness ;  at  others,  they  are  produced  by  chronic 
inflammation  of  the  parts.     In  many  cases  they  are  undoubtedly 
of  venereal  origin,  being  the  sequelae  of  syphilis. 

151.  Treatment. — If  the  tumors  are  small,  they  may  be  easily 
removed  by  clipping  them  off  with  the  scissors  or  knife.     If  they 
are  large,  they  will  have  to  be  removed  with  the  ligature,  to  pre- 
vent the  hemorrhage,  which   is  always  very  considerable  when 
they  are  excised.     After  they  have  been  removed,  caustics  should 
be  applied  to  their  roots,  to  disorganize  them,  and  prevent  their 
recurrence ;  probably  the  best  caustic  that  can  be  used  in  this 


V  U  L  V  A  II      K  X  T  HOC  K  I,  K.  93 

case,  is  Carbolic  Acid  ;  let  it  be  thoroughly  applied  with  a  pine 
pencil — so  thoroughly  as  to  reach  the  base  of  the  growths.  If 
one  application  is  not  sufficient  to  entirely  destroy  them,  it  may 
be  repeated  in  two  or  three  days.  If  Chromic  Acid  should  be 
used,  then  just  enough  to  wet  the  root  of  the  tumor;  for  if  it 
is  too  freely  used,  it  will  produce  great  inflammation  and  disor- 
ganization of  the  surrounding  parts. 

152.  Should  there  be  any  suspicion  that  these  excresences  are 
of  venereal  origin,  the  proper  treatment  for  syphilis  should  be 
employed. 

158.  Quietness  and  rest  is  necessary  for  a  few  days  after  their 
removal.  Should  there  be  much  irritation,  following  their  re- 

CD 

moval,  or  the  application  of  the  caustic,  the  parts  may  be  fre- 
quently bathed  with  cold  water,  which  Avill  generally  subdue  it. 

VULVAR   EXTEROCELE. 

154.  This  consists  of  a  hernia  of  the  small  intestine,  which  has 
forced  its  way  downward  by  the  side  of  the  vagina  into  one  of  the 
labia,  where  it  forms  a  tumor,  which  both  raises  up  the  skin,  thus 
showing    itself   externally,   and    projects  inward    into  the  vulva 
This  variety  of  displacement  is  of  very  rare  occurrence ;  it  was 
first  described  by  Sir  Astley  Cooper,  under  the  name  of  pudcndal 
hernia.     It  may  be  diagnosed  from  other  affections  of  the  vulva, 
by  the  fact,  that  when  the  patient  coughs  or  bears  down,  the  tumor 
will  become  hard  and  tense,  and,  in  coughing,  there  may  be  felt  a 
distinct  impulse  or  succussion  ;  the  diagnosis  is  also  assisted  by 
the  fact,  that  in  nearly  every  case  it  is  reducible. 

155.  Treatment. — When  called  to  a  case  of  this  kind,  our  first 
object  is  to  reduce  the  hernia.     In  order  to  accomplish  this  with 
facility,  the  patient  should  be  placed  upon  her  back,  with  her  hips 
elevated,  and  the  thighs  flexed  upon  the  abdomen,  in  order  to  take 
off  the  tension  of  the  abdominal  muscles.     The   operator    should 
then  introduce  one  or  two  fingers  into  the  vagina,  to  support  the 
vaginal   wall,  and   prevent  its  yielding  as   the  intestine  is  passed 
up,  while    with    the    other   hand    he    makes    steady  compression 
upon  the  tumor, — passing  the  boAvel  upward  in  the  direction  of 
the  axis  of  the  pelvic  cavity.     We  may  know  that  the  bowel  has 


94  DISEASES     OF     AVOMEX. 

been  reduced  by  the  void  that  it  leaves  in  the  labium  and  cor- 
responding portion  of  the  vagina.  For  the  purpose  of  preventing 
a  displacement,  the  conoidal  pessary  may  be  used;  it  should  be 
placed  with  its  base  upward,  and  retained  by  means  of  a  bandage  ; 
or  an  India  rubber  bottle,  as  we  have  recommended  in  prolapsus 
of  the  bladder,  might  be  found  to  answer  a  very  good  purpose. 

VAGINAL  EXTEROCELE. 

156.  This  is  but  a  species  of  the  same  variety  of  hernia  ;  it 
presents  itself  in  the  canal  of  the  vagina,  instead  of  passing  down 
to  the  vulva.    We  notice  this  here,  from  the  fact  that  the  diagnosis 
and  treatment  are  the  same  in  both  varieties. 

PRURITUS  OF  THE  VULVA. 

157.  I  have  already  mentioned    pruritus    of  the  vulva  as  an 
attendant  symptom  in  superficial   inflammation,  and   some   other 
diseases  of  the  vulva ;  it  is.  however,  of  more  common  occurrence 
as  a  symptom  in  other  diseases,  than  those  of  the  vulva.     Thus,  it 
may  occur  during  pregnancy,  from  disease  of  the  cervix  uteri, 
from  leucorrhea,  from  disease  of  the  bladder,  or  meatus  urinarius, 
from  disease  of  the  rectum,  especially  from  the  presence  of  anal 
worms,  the  ascaris  vermicularis,  from  the  presence  of  the  pediculus 
pubis  at  the  roots  of  the  hair  of  the  genitals,  etc.    In  other  cases, 
none  of  these  causes  can  be  detected ;  the  pruritus  appearing  to 
"be  due  to  a  perverted  action  of  the  nerves  of  the  part. 

158.  The  symptoms  of  this  affection,  according  to  Dr.  Ashwell, 
are  a  tormenting  irritation  of  the  vulva,  sometimes  affecting  the 
whole  genital  fissure,  and  occasionally  the  vagina  some  way  down, 
and  the  mons  veneris.     Where  this  latter  part  is  implicated,  it 
should   be  ascertained  whether  there  be  parasite  animals  at  the 
roots  of  the  hair. 

159.  "  The  itching  is  increased  by  the  warmth  of  the  bed,  by 
lull    and    stimulating    diet,  high   temperature,   and   fatigue  from 
walking.     If  the  parts  be  examined  after  the  disease  has  existed 
for  some  time,  little  pimples,  slightly  elevated,  will  be  discovered ; 
and,  if  the  patient  has  scratched  severely  with  her  nails,  or  even 
only   with  the  ends  of    the    fingers,   these  spots  will    be  highly 
inflamed, — an  acrimonious  discharge,   slightly  tinged  with  blood, 


PRURITUS     OF     THE     VULVA.  l).j 

oozing  from  them.  In  a  more  advanced  stage  of  the  affection, 
these  points  may  be  covered  with  a  brown  crust,  the  surroundin^ 
membrane  being  of  a  dark  color,  and  somewhat  thickened. 

160.  "  Venereal  thoughts  are  often  excited  from  this  irritation 
of  the  sexual  organs,  and  they  sometimes  become  so  dominant  and 
imperious  as  to  constitute  almost  a  mania.  There  is  also  some- 
times leucorrhea.  which  weakens  the  vagina,  and  pelvic  weight 

O  /  1  O 

and  pains  arc  added  to  the  other  local  symptoms.  After  a  time, 
the  genitals,  especially  the  labia  arid  nymphse,  become  somewhat 
enlarged,  and  the  mucous  membrane  occasionally  loses  its  vascular 
appearance,  and  assumes  a  white,  sodden  look.  The  general  health 
soon  suffers  ;  the  constant  loss  of  rest,  and  watchfulness,  induces 
much  nervous  derangement ;  the  bowels  become  irregular ;  the 
appetite  impaired ;  and  defective  nutrition  is  seen  in  the  loss  of 
flesh  and  palid  aspect  of  the  patient." 

161.  Treatment. — When  consulted  upon  a  case  of  this  kind, 
our  first  object  should  be  to  ascertain  the  producing  cause.    Thus, 
the  condition  of    the   bladder,   the   urethra,   vaginal   wall,  cervix 
uteri,  rectum,  etc.,  should  be  carefully  ascertained.    If  the  disease 
arises  from  any  of   the  causes  before-mentioned,  our  treatment 
should  be  directed  to  the  removal  of  this  cause ;   for,  with  this 
removal,  in  many  cases,  wre  will   have  a  cessation  of  the  pruritus. 
Without  this,  we  can  not  expect  a  cure  of  this  affection  ;  and  our 
efforts  directed  to  the  arrest  of   the  external   symptoms,  might 
greatly  aggravate  the  primary  and  more  important  disease. 

162.  Many  agents  have  been  used  as  local  applications  for  the 
relief  of  the  pruritus,  and  with  a  variable  degree  of  success.     In 
the  pruritus  attending  pregnancy,  Professors  Dewees  and  Meigs 
recommend  the  lotion  of  Borax  and  Morphia.   Professor  Meigs  says, 
"  having  been  consulted  a  great  many  times  for  the  relief  of  pruritus 
vulvae,  and  most  frequently  in  pregnant  women,  I  have  rarely  had 
occasion  to  order  any  thing  more  than  the  following  formula, — viz; 

R   Soda  Borat,  5  ss. 

Morphia  Sulphas,  gr.  ij. 
Aq.  Rosge,  distillat,  %  iiij. 
M — F.  to  sec.  art.  misturse. 


96  DISEASES     OF     WOMEN. 

I  direct  the  person  to  apply  it  thrice  a  day  to  the  affected  parts,, 
by  means  of  a  bit  of  sponge  or  a  piece  of  linen, — taking  the  pre- 
caution first  to  Avash  the  surfaces  with  tepid  water  and  soap,  and 
to  dry  them  before  applying  the  lotion." 

163.  In  some  cases  permanent  relief  will   only  be  obtained  by 
the  use  of  internal   remedies,  and  these  will   be  selected  by  the 
special  indications.     Ehus  is  indicated  by  the  burning  pain  ;  Apis 
by  the  itching  and  burning  extending  to  the  urinary  passages  ; 
Collinsonia  by  the  sense  of  contraction  and  pain  about  the  anus  ; 
Hamamelis  by  the  sense  of  fullness  and   inclination  to  prolapse: 
Macrotys  by  the  lumbar  pain,  painful  menstruation,  and  pain  in 
the  thighs  ;  Pulsatilla  by  the  nervousness  aud  mental  despon- 
dence ;  Bromide  of  Ammonium  by  hysterical  symptoms,  oppres- 
sion in  the  chest,  loss  of  consciousness,  etc. 

164.  I  like  the  lotion   of  Salicylic  Acid  and  Borax  as  well  as 
the  one  of  Dr.  Meigs,  and  if  there   is  some  erosion,  it  will  prove 
better. 


CHAPTER    IV. 


DISEASES  OF  THE   URETHRA. 

INTRODUCTION  OF  THE  CATHETER. 

165.  Before  describing  the  diseases  to  which  this  canal  is  liable, 
it  nay  be  well  to  give  some  information  in  regard  to  the  use  of 
the  catheter.  This  may  seem  like  a  very  simple  operation,  which 
any  one  could  perform ;  but,  when  the  young  practitioner  has 
occasion  to  test  his  skill,  without  he  has  thoroughly  acquainted 
himself  with  the  anatomy  of  the  parts,  he  will,  in  all  probability, 
find  much  difficulty  in  its  introduction,  and  may,  unknowingly, 
inflict  great  injury  upon  the  patient. 


INTRODUCTION     OF     THE     CATHETER.  97 

166.  We  distinguish  four  different  conditions  of  the  parts,  in 
either  of  which  the  catheter  may  have  to  be  used.     First,  in  the 
unmarried  woman  ;  /Second,  in  the  married  woman  ;    Third,  during 
pregnancy  ;  Fourth,  during,  or  soon  after,  delivery.     These  differ- 
ences consist  either  in  an  alteration  of  the  position  of  the  meatus 
urinarius,  or  in  the  direction  of  the  urethra. 

167.  By  referring  to   the  anatomy  of  these  organs,  it  will  be 
seen,  that  the  external  orifice  of  the  urethra  is  situated  about  one 
inch  farther  inward  than  the  clitoris.     At  its   commencement  in 
the  anterior  wall  of  the  vagina,  it  is  somewhat  protuberant,  and 
the  orifices  of  numerous   mucous  ducts  may  be  seen   around  it. 
From  this  point,  the  canal   of  the  urethra  extends  upward  and 
backward,   along   the    anterior   wall    of   the   vagina,    in  which  it 
appears  to  be   imbedded ;  as  its  projection  into  the   canal  of  the 
vagina  can  be  plainly  felt.     The  length  of  the  urethra  is  between 
one  and  two  inches.     The  differences  named,  consist  in, 

1st.  In  young  persons,  the  external  orifice  of  the  urethra  is 
immediately  below  the  symphisis  pubis,  and  nearly  level  with  the 
anterior  face  of  that  bone. 

2d.  In  women,  who  have  borne  many  children,  the  urethra  is 
retracted  or  shortened,  so  as  to  be  rarely  more  than  an  inch  and 
a  quarter  in  length  ;  and  the  orifice  will  be  found  behind  the  pubis, 
near  its  posterior  face. 

3d.  In  any  enlargement  of  the  uterus,  whether  it  be  the  result 
of  gestation  or  disease,  the  direction  of  the  urethra  will  change 
with  the  ascent  of  the  uterus,  so  that  in  the  latter  stages  of  preg- 
nancy, the  urethra  will  be  found  nearly  perpendicular ;  passing 
along  the  internal  surface  of  the  symphisis  pubis  ;  and  the  meatus 
will  be  found  behind  the  pubis,  near  its  posterior  face. 

4th.  During  labor,  the  direction  of  the  urethra  will  be  the 
same,  but  the  descent  of  the  head  into  the  pelvis,  in  some  cases, 
so  compresses  the  urethra,  that  the  catheter  can  with  difficulty  be 
introduced.  In  this  case,  it  is  recommended  to  place  two  or  three 
fingers  of  one  hand  on  the  head,  and  carefully  raise  it;  and  with 
the  other,  introduce  the  catheter.  Immediately  after  labor,  the 
tissues  are  very  much  relaxed,  and  considerable  care  must  be  used 
in  its  introduction. 
7 


98  DISEASES     OF     WOMEN. 

168.  In  introducing  the  catheter,  the  patient  should  be  placed 
on  her  back,  with  the  thighs  flexed,  and  brought  to  the  edge  of  the 
bed,  so  as  to  facilitate  the  manipulations  of  the  physician.    Under 
ordinary  circumstances,  exposure  of  the  patient  is  neither  neces- 
sary nor  justifiable.     The  index  finger  of  one  hand  should  then  be 
introduced  into  the  vagina,  carrying  its  radial  surface  along  the 
vestibule,  until  it  comes  in  contact  with  the  protuberance  marking 
the  orifice  of  the  urethra ;  if  this  elevation  is  absent,  as  is  some- 
times the  case,  the  finger  should  be  carried  upward,  until  it  comes 
in  contact  with  the  projecting  wall  of  the  urethra ;  the  finger  should 
then  be  gently  withdrawn  along  the  course  of  the  urethra,  when 
it  will  come  in  direct  contact  with  the  meatus  urinarius.     Having 
then  one  finger  at  the  orifice  of  the  urethra,  this  serves  as  a  guide 
for  the  catheter,  which  being  previously  oiled,  is  introduced  by 
the   other   hand.     Having  carried   the   point   of   the    instrument 
along  the  finger,  the   apex  of  which  is  placed  on  the  rneatus,  it 
will  be  found  to  readily  enter  the  orifice.     It  should  then  be  in- 
troduced in  the  direction  of  the  urethra,  carefully  passing  it,  using 
but  gentle  force,  until  it  enters  the  bladder;  this  may  be  known 
by  the  discharge  of  urine,  which  should  be  received  in  some  small 
vessel  prepared  for  the  purpose. 

URETHRITIS. 

169.  This  affection,  though  rare,  is  sometimes  met  with  by  the 
physician.     It  may  be  either  acute  or  chronic,  though  in  all  the 
cases  that  I  have   seen  reported,    the   chronic   disease   always 
resulted  from  an  acute  attack.     It  may  occur  in  women  of  any 
age,  and  independently  of  any  venereal  affection. 

170.  The  symptoms  of  this  disease  are:   constant  pain  along 
the  course  of  the  urethra,  which  is  greatly  increased  by  passing 
the  urine ;  there  is  also  considerable  bearing  down ;  the  urine  is 
passed  with  great  difficulty,  and  but  a  small  quantity  at  a  time ; 
the  patient  having  a  constant  desire  to  evacuate  the  bladder.     In 
some  cases,  indeed,  it  can  not  be  passed  at  all,  for  as  soon  as 
the  urine  touches  the  inflamed  mucous  membrane,  spasmodic  con- 
traction takes  place,  which  prevents  the  excretion  of  even  the 
smallest  quantity.     Upon  introducing  the  finger,  and  passing  it 


UKKTlfRlTIS.  99 

over  the  course  of  the  urethra,  it  will  be  found  to  be  extremely 
painful,  iu  acute  cases  ;  and  in  the  chronic,  it  Avill  be  so  tender, 
that  the  patient  can  bear  but  very  little  pressure  on  it  ;  in  these 
cases,  sexual  intercourse  is  very  distressing.  If  the  orifice  of  the 
urethra  be  dilated,  the  mucous  membrane  is  seen  to  be  unusually 
florid,  and  it  may  be  so  swollen,  as  to  be  everted,  and  protrude 
from  the  orifice  ;  the  passage  of  the  catheter  gives  very  severe 
pain,  which  does  not  extend,  however,  to  the  bladder.  There  is 
no  discharge  attending  the  acute  stage  of  this  disease,  and  it  may 
thus  be  diagnosed  from  gonorrhea  ;  but  in  t\vo  eases  of  chronic 
inflammation,  which  I  attended,  there  was  ulceration,  and  a  very 
small  discharge  of  muco-purulent  matter. 

171.  This  disease  may  arise  simply  from  cold,  and  maybe  asso- 
ciated with   considerable  irritation  of  the  bladder,  and  sometimes 
kidneys.     The  urine  is  scanty  ;  there  are  frequent  calls  to  pass  it, 
and  the  patient  complains  of  scalding  and  irritation  of  the  vulva.. 
In  some  cases  it  will  be  associated  with  disease  of  the  vagina  and 
uterus,  and  will  only  be  relieved  when  this  is  cured.     Prostitutes 
not  unfrequently  suffer  from  severe  urefhral    irritation,  and  some 
urethritis,  and  sometimes,  though   the  disease  is  not  gonorrhoeal, 
it  may  be  transmitted  to  others.     I  am  also  satisfied  that  promis- 
cuous intercourse  on  the  part  of  the  husband  may  sometimes  give 
rise  to  an   irritation  Avhieb   may  be  transmitted   to   the  wife,  and 
assume  the  form  of  simple  urethritis. 

172.  The  diagnosis  is  not  always  easy,  and  when  persons  have 
been  exposed  it  is  sometimes  difficult  to  determine  whether  it  is 
simple  urethritis  or  gonorrhoea.     There  is  very  much  difference  in 
persons  with  regard  to  this.     A  woman  may  cany  gonorrhoea  for 
months,  and  suffer  very  little    from   it,  whilst  others  would  suffer 
most  intensely.     So   in  this  case  :  the  simple   inflammation  may 
run  as  high,  there  may  be  as  much  suffering,  and  as  abundant  a 
discharge,  as  in  the  severest  cases  of  gonorrhoea. 

When  a  per»on  has  suffered  from  urethritis  once,  especially  if 
not  properly  treated,  the  urethra  is  likely  to  be  left  in  an  irritable 
condition,  and  may  be  a  life-long  source  of  annoyance.  Every 
functional  Avrong  of  the  reproductive  apparatus  seems  to  manifest 
itself  here  by  sympathy,  and  after  a  time  the  bladder  becomes  per- 
manently diseased,  its  walls  and  mucous  membrane  either  being 


100  DISEASES     OF     WOMEN. 

thickened,  or  from  atony  of  bladder  and  vagina  there  is  partial 
prolapse  of  the  bladder.  In  both  cases  there  will  probably  be 
increased  secretion  of  mucus,  and  a  plentiful  deposit  of  the  triple 
phosphates.  Thickening  of  the  tissues  of  the  urethra  may  also 
result,  and  the  development  of  those  irritable  epithelial  growths 
sometimes  known  as  irritable  tumors  of  the  urethra. 
The  following  case  will  illustrate  the  usual  symptoms  : 
Mrs.  M.,  aged  17,  had  been  recently  married,  was  attacked  Feb. 
9,  1857,  with  great  pain  and  tenderness  along  the  course  of  the 
urethra,  and  difficulty  in  micturition  ;  the  urine,  as  it  was  passed, 
producing  excessive  pain,  and  sometimes,  as  she  said,  appearing 
to  stop  in  the  middle  of  the  passage.  After  the  first  day,  she 
complained  of  a  pressing,  or  bearing  down,  which  was  greatly 
increased  whenever  she  attempted  to  evacuate  the  bladder.  For 
the  first  three  days,  there  was  a  considerable  discharge  of  blood 
from  the  urethra,  but  after  this  it  gradually  ceased.  I  Avas  called 
to  see  her  on  the  second  day  of  the  attack.  On  making  an  exam- 
ination, I  found  considerable  heat  in  the  lower  portion  of  the 
vagina,  which  was  more  apparent  along  the  course  of  the  ure- 
thra, and  more  especially  near  the  meatus  urinarius.  The  ten- 
derness of  the  parts  was  so  great  that  I  could  scarcely  make  an 
examination.  Upon  separating  the  labia  the  meatus  could  be 
seen  very  much  swollen  ;  the  orifice  was  dilated,  and  the  mucous 
membrane  slightly  everted.  There  were  also  slight  constitutional 
symptoms  present.  She  had  been  married  five  or  six  days,  and 
from  the  first  she  had  felt  some  difficulty  in  passing  her  urine,  and 
considerable  tenderness  of  the  parts. 

173.  Treatment. — If  the  disease  is  acute  and  severe  it  is  best 
that  the  patient  should  have  rest  in  a  recumpent  position,  espe- 
cially if  near  the  menstrual  period,  or  associated  with  metritis. 
In  this  case  I  like  the  action  of  Yeratrum  and  Gelseminum,  or 
Veratrum  and  Macrotys,  if  there  is  uterine  or  pelvic  pain.  Some- 
times a  hot  fomentation  of  hops,  stramonium  or  poppy  heads  give 
great  relief  at  first,  and  if  there  is  much  vesical  tenesmus  this 
may  be  supplemented  by  a  rectal  enema  of  Tinct.  Opium  and 
Lobelia.  If  the  bowels  are  constipated,  and  the  patient  suffers 
from  this,  a  free  evacuation  may  be  had  by  the  use  of  Crab  Or- 
chard Salts  and  Sulphur,  or  if  easily  influenced,  by  a  Seidlitz 
powder. 


URETHRITIS.  101 

There  are  cases  in  which  we  would  give  Eh  us,  Bryonia,  Dios- 
corea,  Eryngium,  Pulsatilla,  Apis,  Gossypium,  or  even  Copaiba 
and  Cubebs,  early  in  the  disease.  Our  rule  is— and  we  find  it 
good  policy  to  follow  it  in  all  cases — to  give  any  remedy  that  may 
be  specially  indicated  without  reference  to  the  situation  or  the 
name  of  the  disease.  The  burning  character  of  the  pain,  pain  in 
forehead,  peculiar  appearance  of  the  papillae  of  tip  of  tongue,  calls 
for  Ehus.  The  Bryonia  will  be  called  for  by  cutting  pains  in  the 
region  of  the  bladder,  almost  always  associated  with  an  inclina- 
tion to  cough  ;  tbe(Dioscorea  by  abdominal  pains  and  tenderness; 
the  Eryngium  by  burning  in  the  bladder,  constant  desire  to  pass 
water,  and  painful  micturition  ;  Pulsatilla  by  the  nervousness  and 
fear;  Apis  by  the  itching  and  burning  in  the  parts;  Gossypium 
by  the  dribbling  of  urine,  or  by  non-appearance  of  menses,  if  it 
is  time  for  them  ;  Copaiba  and  Cubebs  b_y  the  abundant  yellow 
purulent  discharge. 

As  the  disease  goes  along  the  acute  somptoms  subside,  and  the 
patient  complains  only  of  difficulty  in  passing  water,  uneasiness 
in  its  passage,  a  sensation  of  bearing  down,  and  more  or  less  dis- 
charge from  the  vagina  or  urethra.  It  may  be  sufficient  to  estab- 
lish an  unpleasant  leucorrhoea,  or  even  permanent  displacement 
of  the  uterus.  Hence  the  remedies  must  be  carefully  selected 
from  such  as  have  been  named  ;  or  we  may  think  of  tbe  Cannabis 
Indica,  Staphysagria,  Euphorbia  Hypericifolia,  Apocynum,  Phos- 
phorus, Hamamelis,  and  others. 

As  a  general  rule,  I  like  the  topical  action  of  Salicylic  Acid  and 
Borax  better  than  any  thing  I  have  used.  If  it  becomes  neces- 
sary to  inject  the  urethra,  nothing  is  so  good  as  a  solution  of  Phos- 
phate of  Hydrastia. 

IRRITABLE  URETHRA. 

174.  In  the  last  few  years  we  have  had  many  cases  of  irritable 
urethra.  It  is  not  confined  to  public  women,  but  is  usually  the 
result  of  sexual  excesses. 

The  patient  complains  of  burning  or  scalding  along  the  course 
of  the  urethra,  frequent  desire  to  pass  water,  and  tenesmus.  In 
eome  cases  it  is  paroxysmal,  the  patient  suffering  severely  for  a 
time,  and  then  for  some  hours  having  relief.  In  some  cases  it  is 
only  felt  during  the  day,  and  especially  if  she  is  much  on  her 


102  DISEASES      OF      WOMEX. 

feet,  but  in  others  the  patient  lias  to  pass  water  several  times 
during  the  night,  and  suffers  constantly.  Pretty  soon  you  will 
Bee  it  wearing  upon  the  general  health,  and  as  weeks  go  by,  the 
patient  has  a  worn  and  haggard  appearance,  and  complains  of 
various  functional  lesions. 

175.  Treatment. — I  have  obtained  the  best  results  in  these  cases 
from  the  use  of  Hhus,  Apis  and  Eryngium,  according  to  the  spe- 
cial indications  heretofore  named.     I  select  the  remedy,  and  use 
it  in  alternation  with  Aconite.     Prof.  King's  prescription  of  Ela- 
terium  will  be  found  a  specific  in   those   cases  in  which  there  is 
inflammation  of  the  base   of  the  bladder,  with   deep  pain   and 
tenesmus.     Of  a  tincture  of  Elaterium  we  would   give  twenty 
drops  three  times  a  day,  until  it  acted  upon  the  bowels,  then  in 
doses  of  five  drops. 

If  there  is  frequent  micturition  with  pain  and  great  tenesmus, 
extending  to  the  bladder,  I  would  recommend  Stramonium,  as- 
follows  :  R  Tinct.  Stramonium,  oss-5  Comp.  Tincture  Cardamom, 
siiiss.;  from  half  to  one  teaspoonful  every  two  or  three  hours.  If 
the  patient  has  been  in  the  habit  of  using  Opium,  the  dose  will 
be  larger. 

When  the  disease  is  persistent,  and  resists  the  action  of  reme- 
dies, forcible  dilatation  of  the  urethra  may  be  proposed  as  a  radi- 
cal cure.  Usually  the  patient  will  have  to  be  placed  under  the 
influence  of  chloroform,  when  a  large  bougie  or  catheter  may  be 
passed,  followed  by  one  as  large  as  the  forefinger  ;  or  the  finger 
well  oiled  may  be  passed  quite  as  well.  The  patient  is  kept  in  a 
recumbent  position,  and  full  doses  of  Yeratrum  are  given.  The 
operation  is  repeated  in  two  or  three  days,  usually  Avithout  the 
chloroform. 

STRICTURE  OP  THE  URETHRA. 

176.  This  is  of  very  rare  occurrence  in  the  female,  owing  to 
the  large  size  and  great  dilatability  of  this  canal.     The  symptoms 
of  this  affection  are,  a  difficulty  in  micturition,  the  urine  passing 
in  a  small  stream,  and  accompanied  with  pain ;  when  the  catheter 
is  passed,  the  difficulty  can  readily  be  detected. 

177.  Treatment. — All  the  cases  that  I  have  seen  reported,  have 


OCCLUSION     OF     TIIK     URETHRA.  103 

neon  successfully  treated  by  dilatation,  with  graduated  bougies. 
The  best  bougie  for  this  purpose,  probably,  is  the  gum  elastic,  or 
gutta  percha  ;  beginning  with  one  of  small  size,  and  gradually 
enlarging  it,  until  the  canal  has  acquired  the  proper  size.  The 
bougie  should  be  passed  beyond  the  stricture,  and  retained  for  ten 
or  fifteen  minutes  each  time,  when  it  will  be  found  that  a  larger 
size  will  be  readily  admitted  the  next  day.  The  occasional  use  of 
the  bougie  should  be  continued  for  some  time  after  the  stricture  is 
removed,  to  perfect  the  cure. 

OCCLUSION  OF  THE  URETHRA. 

178.  Occlusion  of  the  urethra  is,  in  general,  a  congenital  affec- 
tion,  and  may  exist   independently  of   any  malformation   of  the- 
other   genital    organs.     The    malformation    generally   consists    of 
merely    a    thin    membrane,    stretched    across    the    orifice    of   the 
urethra,  though  cases  have  been  reported   in   which  the   closure 
affected  a  larger  portion,  or  even  the  whole   canal.     The  urethra 
may  be  mechanically  obstructed  by  cohesion  of  the  labia. 

179.  A  strict  examination  should  be  made,  when  the  napkins 
of  the  infant  are  found  not  to  be  wetted  with  the  usual  discharge 
from  the  bladder,  and  where,  after  the  meconium  has  been  evacu- 
ated from  the  bowels,  the  infant  still  continues  to  cry  and  to  strain 
without  effect. 

180.  Treatment. — Where  the  meatus  is  obstructed  by  a  mem- 
brane, it  may  yield  to  slight  pressure;  or  if  this  should  not  remove 
it,  the    membrane    may  be    punctured   with   a   narrow    bistoury, 
keeping  the  passage  open,  by  the  introduction  of  a  small  catheter, 
for  two  or  three  days. 

Where  the  obstruction  occupies  the  greater  portion  of  the 
canal,  it  has  been  recommended  to  puncture  the  bladder  by  means 
of  a  delicate  trocar,  which  should  be  introduced  at  the  meatus,  and 
carried  along  where  the  urethra  should  be,  until  it  enters  the 
bladder.  Or,  if  this  can  not  be  done,  the  bladder  should  be  punc- 
tured through  the  vagina.  These  cases  are  always  dangerous,  yet 
the  physician  should  use  such  means  as  would  give  a  probability 
of  relief. 


104  DISEASES     OF     WOMEN. 

VASCULAR  TUMOR  OF  THE  MEATUS  URINARIUS. 

181.  These  tumors  are  by  no  means  of  unfrequent  occurrence. 
They  may  be  developed  in  patients  of  any  age,  though  they  more 
frequently  attack  the  young,  whether  married  or  single. 

182.  According  to  Dr.  Ashwell,  this  tumor  is  generally  pedicu- 
lated  and   movable,  attached  to  one  part  of  the  margin  of  the 
meatus  urinarius,  or  just  within  the  urethra.     Its  two  prominent 
characteristics    are,   great  vascularity   and    exquisite    sensibility. 
Sometimes  these  growths  are  not  movable,  but  appear  like  several 
raised    coalesced    granulations ;    or,    occasionally,    two    or   more 
isolated  and  independent  ones  may  be  seen  near  together.     Every 
now  and  then  they  extend  partly  along  the  urethra,  and  may  even 
be  located  at  the  neck  of  the  bladder.     They  are  covered  by  a 
very  delicate  membrane,  which  is  often  broken  by  being  touched 
during  examination,  and  blood  exudes  from  the  soft,  feeble,  and 
injected  capillaries.     They  vary  in  color,  from  a  pale  rose  tint  to 
the  deepest  red ;  they  are  generally  small,  not  being  larger  than 
a  pea  in  most  cases,  yet  in  some  cases  they  have  been  much 
larger. 

183.  Symptoms. — The    symptoms    that   arise   from   this,    are 
mainly  owing  to  the  extreme  sensibility  of  the  tumor.     Thus,  if  it 
is  so  situated  that  the  urine  comes  in  contact  with  it,  the  act  of 
passing  water  produces  great  distress,  and  this  is  usually  one  of 
the  most  prominent  symptoms.     There  is  also  constant  pain  in 
the  vulva,  which  is  increased  by  motion ;  _  sometimes  this  pain  is 
accompanied  by  a  sense  of  weight,  the  urethra  and  bladder  become 
irritable,  and  the  frequent  desire  to  micturate  is  suppressed  by 
the  dread  of  the  pain  which  it  excites.     Sexual  intercourse  is 
intensely  painful,  and  is,  therefore,  obliged  to  be  suspended.     No 
mistake  can  be  made  in  the  diagnosis,  if  an  examination  be  made. 

184.  Treatment. — No  means  that   may  be  made  use  of,  will 
have  the  least  effect,  until  the  tumor  is  removed ;  this  may  be 
done  by  ligature,  caustic,  the  knife  or  scissors.     When  the  tumor 
is  large,  or  has  a  thick  base,  the  ligature  would  be  preferable, 
from  the  fact  that  there  is  less  hemorrhage  accompanying  it,  and 
less  liability  of  a  return  of  the  tumor.     The  use  of  the  ligature  is 
very  painful   in   these   cases,  and   if  the   tumor  be   small,  and 


TUMOR     OF     THE     ME  AT  US     URINARIUS.  105 

attached  by  a  pedicle,  the  better  plan  would  be  to  cut  them  off 
close  to  the  mucous  membrane,  with  a  pair  of  curved  scissors 
The  urethra  should  always  be  dilated  and  examined,  to  see 
whether  there  is  any  growth  within  it;  if  there  is,  this  should 
also  be  removed.  Whatever  means  is  adopted  for  the  removal  of 
the  tumor,  without  the  base  of  it  is  destroyed  by  caustic,  it  will 
rapidly  reappear  ;  as  soon,  then,  as  the  tumor  is  removed,  whether 
by  the  ligature  or  scissors,  its  base  should  be  destroyed,  either  by 
the  application  of  Nitric  Acid,  or  a  solution  of  the  Chloride  of 
Zinc,  carefully  shielding  the  adjacent  parts  from  injury.  This 
should  be  repeated,  at  intervals,  until  the  disposition  to  reproduc- 
tion has  entirely  ceased.  It  was  from  this  disposition  of  the 
tumor  to  reappear,  that  Dubois  and  Cullerier  recommended 
cauterization  without  excision.  Mad.  Boivin  sprinkles  the  parts 
with  powdered  alum.  Where  a  considerable  extent  of  the  mucous 
membrane  of  the  urethra  is  affected,  Dr.  Churchill  recommends 
the  application  of  the  Nitric  Acid.  His  means  of  applying  this, 
is,  to  take  a  pointed  pencil  of  soft  wood,  dip  it  in  the  strong  nitric 
acid,  and  gently  put  it  in  the  urethra  as  far  as  may  be  necessary ; 
this,  though  tedious,  he  has  always  found  effectual.  One  of  our 
practitioners  informed  me,  that  in  one  case  he  destroyed  the 
morbid  growth  in  the  urethra,  by  using  pulverized  Alum  and 
Sanguinaria,  equal  parts.  His  mode  of  using  this  was  to  take  a 
tube  about  the  size  of  a  common  catheter,  fill  it  with  the  powder, 
and  carefully  introduce  it  into  the  urethra,  as  far  as  the  morbid 
growth  extends ;  then,  as  he  withdrew  it,  he  pushed  the  powder 
out  with  a  small  rod  made  to  fit  the  tube :  this  covered  the  entire 
growth  with  the  powder.  The  introduction  of  this  excited  con- 
siderable inflammation,  but  it  was  readily  subdued  by  the  use  of 
cold  applications.  Two  applications  of  this  powder  removed  the 
growth,  which  has  since  shown  no  tendency  to  return. 

185.  After  removing  these  tumors,  the  patient  should  be  kept 
quiet,  and  all  symptoms  of  inflammation  should  be  subdued  by 
<5old  applications  and  vaginal  injections. 


106  DISEASES      OF      WOMEN. 

FOREIGN  BODIES  ix  THE  URETHRA. 

186.  These  consist  of  substances,  which,  in  some  manner,  have 
been  introduced  from  without,  and  calculi  which  have  passed  from 
the  bladder  into  the  urethra.  Of  the  first  variety,  many  different 
substances  have  been  removed,  as  parts  of  a  bougie,  pencils,  pins, 
pieces  of  wood,  hair  pins,  etc.  It  is  not  necessary  here  to  inquire 
how  these  articles  gained  admission  into  the  urethra,  but,  how 
they  can  be  removed  with  the  least  injury  to  the  parts.  As  the 
female  urethra  is  very  dilatable,  calculi  of  considerable  size  may 
pass  into  it.  These,  by  contact  with  the  walls  of  the  passage, 
produce  considerable  irritation  and  spasmodic  contraction,  which 
prevents  their  further  passage.  In  either  of  these  cases,  the 
patient  will  so  describe  her  situation,  that  there  can  be  no  difficulty 
in  forming  a  correct  diagnosis.  The  catheter  or  sound  should  be 
introduced  carefully  into  the  urethra,  to  ascertain  exactly  the 
character  and  position  of  the  obstruction.  If  this  can  be  ascer- 
tained, its  removal  should  be  immediately  attempted.  The  best 
instrument  for  this  purpose  is  (whether  the  obstruction  is  a  calcu- 
lus, or  any  other  substance,)  a  pair  of  small  polypus  forceps;  these 
should  be  at  least  two  and  a  half  inches  long  in  the  blades,  so 
that  they  may  be  passed  to  the  neck  of  the  bladder,  or  into  it  if 
necessary.  Having  oiled  the  forceps,  they  should  be  carefully 
introduced,  using  but  a  gentle  degree  of  force,  and  passed  up  until 
they  come  in  contact  with  the  obstruction.  Then,  by  opening 
them  as  much  as  the  urethra  will  permit,  they  may  be  carefully 
passed  up  until  the  offending  substance  can  be  grasped.  Here 
considerable  care  must  be  used,  to  prevent  the  forceps  including 
in  their  grasp  any  part  of  the  mucous  membrane ;  if  this  should 
be  the  case,  it  may  be  known  by  the  pain  it  occasions  when  the 
forceps  are  pressed  together,  and  before  any  retraction  is  made. 
Having  then  obtained  a  firm  hold  on  the  body,  it  should  be  care- 
fully and  slowly  withdrawn,  giving  sufficient  time  between  the 
tractions  to  permit  the  urethra  to  dilate  for  its  passage. 

187.  Should  the  foreign  body  be  so  large,  as  is  sometimes  the 
case  with  a  calculus,  that  it  will  not  pass  without  great  laceration 
of  the  urethra,  the  forceps  should  be  removed,  and  means  used  to 
relax  the  parts.  This  may  be  accomplished  by  using  vaginal 


UREXARY     CALCULI.  107 

injections  of  a  decoction  of  Stramonium,  and  directing  the  patient 
to  sit  over  the  vapor  of  hot  water.  After  it  is  removed,  if  much 
inflammation  should  arise,  it  may  be  subdued  by  cold  applications 
to  the  parts. 

URINARY  CALCULI. 

188.  It  may  be  well,  in  this  connection,  to  give  a  description 
of  the  means  employed,  of  late  years,  to  remove  calculi  from  the 
female  bladder. 

189.  Owing  to  the  great  dilatability  of  the  female  urethra,  cal- 
culi are  frequently  passed,  without  any  assistance,  and,  probably, 
this  is  one  of  the  reasons  why  the  physician  is  less  frequently 
consulted  by  women  suffering  from  stone  than  by  men.     In  proof 
that  the  urethra  can  be  dilated  sufficient  for  the  passage  of  almost 
any  sized  calculi,  Mr.  Brown  gives  the  following  well  authenticated 
cases.     Middleton   relates   a  case  where   a   stone  weighing  four 
ounces,  was  expelled  in  a  fit  of  coughing,  after  lodging  in  the  pas- 
sage for  a  week.     Collet   speaks   of  another  instance,  where  a 
stone  about  as  large  as  a  goose  egg,  after  lying  in  the  meatus  uri- 
narius  seven  or  eight  days,  and  causing  retention  of  urine,  was 
voided  in  a  paroxysm  of  pain.     Dr.  Molineaux  relates  a  case  in 
which  a  woman  voided  a  stone,  of  which  the  longest  circumference 
•was  between  seven  and  eight  inches ;  the  shortest  (in  the  thickest 
parts)  five  and  three-quarter  inches. 

190.  These  instances  are  sufficient  proof,  that  the  urethra  may 
be  dilated  to  give  passage  to  any  calculus  that  could  be  removed 
by  the  sub-pubic   operation  of  lithotomy.     The  objections   that 
have  been  brought  against  the  practice  of  dilatation  are,  First,  that 
it  frequently  takes  a  long  time  and  gives  great  pain  to  dilate  it 
effectually  ;  Second,  that  laceration  is  liable  to  occur ;   Third,  that 
incontinence  of  urine  has  sometimes  followed. 

191.  As  Mr.  Brown  has  fully  answered  these  objections,  I  shall 
quote  from  him.    "First.  The  tediousness  of  the  operation  and  the 
pain  it  produces,  are  objections,  the  whole  force  of  which  has  been 
dissipated  by  the  introduction  of  anaesthetics  into  operative  sur- 
gery ;  and  in  this  case  chloroform  has  a  double  claim  upon  our 
notice.     It  not  only  prevents  all  pain,  but  it  prevents  all  tedious- 


108  DISEASES    OF    WOMEN. 

ness  likewise.  So  long  as  the  patient  is  conscious,  the  process  of 
dilatation  is  rendered  difficult  and  tedious  by  the  contraction  of  the 
sphincter  fibers  of  the  meatus  ;  but,  under  chloroform,  these  fibers 
are  relaxed,  and  the  dilatation  can  be  accomplished  easily  and 
quickly.  Second.  The  second  objection  is  disposed  of  in  the 
same  way.  Laceration  can  only  occur  in  the  walls  of  this  loosely 
arranged  structure,  in  consequence  of  the  rigidity  of  the  muscular 
fiber ;  relax  this  rigidity  by  chloroform  and  the  danger  of  lacera- 
tion no  longer  exists.  Third.  Incontinence  of  urine  does  not 
occur  after  dilatation  under  chloroform,  and  I  think  this  may  be 
thus  explained.  When  the  dilatation  has  been  a  tedious  and  pain- 
ful process,  it  has  been  accomplished  (physiologically)  by  exhaust- 
ing the  irritability  of  the  fibers,  and  thus  rendering  them  power- 
less for  the  time ;  or  (mechanically)  their  structure  may  have 
given  way  under  tension  ;  or  both  these  circumstances  may  have 
occurred;  and  in  either  of  these  occurrences,  subsequent  imperfect 
contraction  and  consequent  incontinence,  are  perfectly  explicable. 
Whereas,  under  chloroform,  there  is  no  wasting  or  bearing  down 
of  the  local  nervous  irritability,  nor,  as  the  rigidity  of  the  canal  is 
destroyed,  is  there  any  danger  of  laceration ;  there  is,  therefore, 
no  probable  cause  for  incontinence,  as  a  subsequent  evil :  I  state 
these  things  advisedly,  and  after  considerable  experience,  having 
had  frequent  occasion  to  dilate  the  female  urethra,  not  only  in 
cases  of  stone  in  the  bladder,  but  in  operating  for  vesico-vaginal 
fistula." 

192.  When,  then,  a  calculus  has  been  discovered  in  the  bladder, 
the  patient  should  be  placed  under  the  influence  of  chloroform, 
and  the  urethra  should  be  dilated,  by  the  use  of  graduated  bougies, 
until  the  finger  can  be  introduced ;  after  the  finger  has  been 
inserted,  dilatation  can  be  rapidly  effected  by  it.  As  soon  as  the 
urethra  is  sufficiently  dilated  to  pass  the  stone,  the  forceps  should 
be  introduced,  and  the  stone  grasped  ;  after  it  has  been  grasped, 
the  forceps  should  be  turned  round,  to  be  certain  that  no  part  of 
the  mucous  membrane  is  included  in  their  grasp  ;  the  stone  should 
then  be  slowly  withdrawn,  carefully  dilating  the  urethra  in  its 
passage. 


OCCLUSION'     OF     T  11  K     VACMXA 


C  FT  AFTER    V. 


DISEASES    OF    THE    VAGINA. 

OCCLUSION  OF  THE  VAGINA. 

193.  Occlusion  of  the  vagina  may  be  either  congenital,  or  the 
result  of  disease.  It  may  also  occur  in  any  part  of  the  canal,  or 
involve  it  in  its  entire  extent.  Congenital  occlusion  may  be  due 
to  an  imperforate  hymen,  or  to  some  malformation  of  the  parts, 
whereby  a  greater  or  less  extent  of  the  canal  is  closed. 

IMPERFORATE  HYMEN. 

104.  The  existence  of  an  imperforate  hymen,  is  not  likely  to  be 
discovered,  until  the  female  has  arrived  at  the  age  of  puberty,  and 
at  the  commencement  of  menstruation.  At  this  time  it  may  be 
suspected,  if  the  female  have  all  the  symptoms  which  precede  and 
accompany  the  menses,  without  any  discharge  of  the  menstrual 
fluid;  and  if  these  symptoms  should  continue  to  recur  at  regular 
intervals,  accompanied  with  a  sense  of  weight  and  fullness  in  the 
vagina  ;  and,  especially,  if  an  enlargement  is  discoverable  in  the 
hypogastrium,  accompanied  with  great  pain  and  tenderness  on 
pressure.  These  symptoms  always  become  ameliorated  in  the 
course  of  a  few  days,  but  return  with  increased  violence  at  each 
successive  menstrual  epoch.  In  these  cases  the  cause  of  the  dif- 
ficulty may  be  easily  detected,  by  an  examination,  which  should 
always  be  requested  when  these  symptoms  are  present.  We  may 
be  certain  that  the  obstacle  that  closes  the  passage  is  an  imper- 
forate hymen,  when  we  discover  between  the  labia  a  hemispherical 
tumor  of  a  livid  or  bluish  color,  soft  and  fluctuating,  and  rendered 
salient  by  the  weight  of  the  contained  blood.  After  having  ascer- 
tained that  the  obstruction  is  caused  by  the  hymen,  we  should 
next  ascertain,  as  near  as  possible,  its  thickness  and  degree  of 
organization.  In  the  most  of  cases,  the  membrane  has  been 


110  DISEASE  S      ()  F      W  0  M  E  X  . 

found  quite  thin,  though  of  considerable  strength  ;  in  some  cases, 
however,  the  membrane  is  thickened  and  indurated,  and  from  a 
fourth  to  three-eighths  of  an  inch  in  thickness. 

195.  Treatment. — In  the  case  of  imperforate  hymen,  where  the 
menstrual  fluid  has  been  retained,  forming  accumulations  in  the 
vagina,  uterus,  and  fallopian  tubes,  it  is  recommended,  by  some 
authors,  to  make  an  incision  through  the  center  of  the  membrane, 
with   a  bistoury,  or  with  a   trocar,  so  that  the  fluid  may  be  grad- 
uallv  evacuated,  thus  lessening  the  liability  to  peritoneal  inflam- 
mation, which  has  so  frequently   occurred   when   the   membrane 
was  entirely  removed,  and  the  fluid  evacuated  at  once.     As  soon 
as   the   fluid   has  been   entirely  evacuated,    the    hymen    may    be 
divided  by  a  crucial  incision,  and  the  flaps  clipped  off  with  a  pair 
of  scissors.      The  vagina  and  uterus  should  be  well  syringed  out 
with  warm  water,  and  a  bandage  applied  around  the  abdomen ; 
the  patient  should  be  kept  quiet,  in  the  horizontal  position,  until 
the  organs  have  regained  their  natural  condition.     In  children,  the 
occlusion  may,  in  general,  be  very  readily  overcome  Avithout  any 
resort  to  the  knife.     The  little  patient  being  placed  in  the  lithotomy 
position,  the  thumb  of  each  hand  should  be  applied  against  the 
obstruction,  and  with  but  a  small  degree  of  force,  the  parts  may 
be  separated. 

196.  It  is  in  those  cases  where  the  obstruction  is  of  long  stand- 
ing, and  where  the  hymen  is   thickened  and  indurated,  that  the 
greatest  difficulty  will  be  experienced.     Two  methods  of  operating 
are  recommended  in  these  cases.     The  first  is  to  make  an  incision 
through  the  upper  part  of  the  hymen  with  a  bistoury,  and  care- 
fully carry  it  down  in  the  median  line  until  the  entire  structure 
is  divided.     Great  care  will  have  to  be  used  in  this  operation,  to 
avoid  injuring  the  urethra,  bladder,  or  rectum.     A  catheter  in 
the  bladder,  and  a  finger  introduced  occasionally  into  the  rectum, 
will    prove    valuable    guides ;    as    soon    as    the   incision  is  large 
enough  to  admit  the  finger,  the  tissues  may  be  broken  down  with 
it,  or  if  the  bistoury  should  still  be  required,  it  may  be  guarded 
by  the  finger  on  the  inside  of  the  obstruction.    Pledgets  of  lint, 
saturated  with  oil  or  the  mild  zinc  ointment,  should  be  introduced 

kept  between  the  cut  surfaces  until  they  have  healed.     If  the 


IMPERFORATK     IIYMEX.  11] 

orifice  should  be  small,  or  contract  after  the  operation,  it  should 
he  dilated  by  the  use  of  the  bougies. 

197.  The  second  method  of  operating  is  by  the  excision  of  the 
entire  hymen.  This  is  recommended  by  Mr.  Baker  Brown  as  the 
safest  operation  that  can  be  performed,  especially  where  there  is 
much  thickening  and  induration,  diminishing  the  liability  to  con- 
traction or  adhesion.  His  mode  of.  operating  is  to  place  the 
patient  in  the  lithotomy  position,  administer  chloroform,  and 
dissect  out  .the  hymen  by  a  semi-circular  incision  on  each  side, 
completely  removing  the  whole  structure.  The  parts  should  be 
dressed  with  oiled-lint,  and  the  dressing  repeated,  from  day  to 
day,  until  the  parts  are  healed.  He  reports  two  cases  success- 
fully treated  in  this  way,  in  neither  of  which  was  the  operation 
accompanied  with  much  hemorrhage. 

197.  Occlusion  may  occur  at  any  portion  of  the  vaginal  canal, 
and   be  of    variable   extent  and   consistence.     Some   cases   have 
been  reported,  in  which  there  was  a  small  passage  connecting  the 
outer   portion  of  the  vagina  with  the   internal  part  surrounding 
the  os  uteri ;  conception  occurred,  and  the  obstruction  had  to  be 
divided  before  the  child  could  be  born.     If  the  occlusion  is  per- 
fect,  and  the   uterine  organs   in  a   normal    condition,  the  same 
symptoms    will    be    present,    as    in    occlusion    from    imperforate 
hymen,    and    even    if   there    be    no    symptoms    of    menstruation 
present,  the  difficulty  should  be  removed,  if  possible,  providing 
that  upon  an  examination  per  rectum,  the  uterus  should  be  found 
in  a  normal  condition. 

198.  Acquired  occlusion. — According  to  Professor  Rokitansky, 
acquired  atresia  may  be  complete  or  incomplete,  and  result  from 
adhesion  of  the  anterior  and  posterior  Avails  of  the  vagina,  to  a 
greater  or  less  extent,  in  consequence  of  excoriation  or  ulcera- 
tion  ;  or  it  may  be  produced  by  flat  or  rounded  cords  that  pass 
horizontally    or    diagonally    across    the    vagina,    and   reduce    its 
caliber.     The  latter  may  consist  of  vaginal  folds,  brought  on  by 
traction,  or  of  the  membranous  bands  left  after  the  cure  of  ulcer- 
ative  loss  of  substance. 

199.  Treatment. — The    treatment    of    congenital    or    acquired 
occlusion  of  the  vagina  is  more  or  less  difficult,  in  proportion  to 


112  DISEASES     OF     WOMEN. 

the  amount  of  the  canal  involved,  and  the  character  of  the  occlu- 
sion. Thus,  if  a  large  portion  of  the  canal  is  involved,  its 
restoration  will  be  difficult,  and  should  not  be  attempted,  unless 
the  condition  of  the  patient  is  such  that  its  restoration  is  indis- 
pensable. So,  likewise,  where  the  occlusion  has  resulted  from 
agglutination  of  the  vaginal  walls  :  the  operation  will  be  difficult 
from  the  extreme  thinness  of  the  structure  in  which  the  division 
has  to  be  made.  Having  decided  to  operate,  the  patient  should 
be  placed  in  the  lithotomy  position,  having  first  evacuated  the 
bladder  and  rectum.  Chloroform  should  be  administered  by  one 
assistant,  while  the  labia  are  to  be  held  apart  by  another.  After 
introducing  a  sound  into  the  urethra,  which  will  enable  the 
operator  to  distinguish  both  the  urethra  and  the  bas-fond  of  the 
bladder ;  and  ascertaining  the  exact  position  of  the  rectum,  and 
as  near  as  possible  the  extent  of  the  intervening  space,  the  opera- 
tion may  be  commenced.  In  this  operation  the  knife  should  be 
used  as  little  as  possible,  the  tissues  being  broken  up  by  the 
fingers  ;  where  the  tissues  do  not  give  way  to  the  pressure  of  the 
fingers,  incisions  should  be  made  to  a  slight  depth,  making  care- 
ful examinations  per  rectum  at  each  incision  ;  thus  using  the 
fingers  as  much  as  possible,  and  the  knife  when  the  adhesions  are 
too  dense  to  be  broken  down  by  them,  the  obstructions  may  be 
removed  up  to  the  cervix  uteri.  The  operator  should  then  ascer- 
tain that  the  os  uteri  is  pervious ;  if  it  is  not,  an  opening  should 
be  made  through  the  canal  of  the  cervix  with  a  trocar  or  bistoury. 
200.  If,  with  occlusion  of  the  vagina,  the  labia  are  adherent, 
they  should  be  carefully  separated  ;  carrying  the  incision  from 
above  downward,  to  the  full  extent  of  the  external  orifice,  a  free 
incision  being  requisite  to  permit  the  necessary  manipulations  to 
remove  the  internal  adhesions.  The  question  will  arise  here,  Shall 
the  incision  be  made  from  above  downward  or  laterally  ?  These 
questions  must  be  decided  by  the  character  of  the  occlusion.  If 
the  occlusion  consist  of  an  intermediate  substance  between  the 
walls  of  the  vagina,  and  the  antero-posterior  diameter,  or  the  dis- 
tance between  the  urethra  and  rectum  is  sufficient  for  a  perpen- 
dicular incision ;  this  should  be  chosen  in  preference  to  the  other, 
from  the  fact  of  the  greater  facility  of  performing  the  operation. 


STRUCTURE     OF     THE     VAGINA.  113 

But  if  occlusion  results  from  adhesion  of  the  walls  of  the  vagina, 
the  incision  will  have  to  be  made  laterally. 

201.  If  there  should  be  much  hemorrhage,  it  may,  in  general, 
be  controlled  by  the  application  of  cold  water.     As  soon  as  the 
parts  are  divided,  pledgets  of  lint,  well  oiled,  should  be  introduced 
into  the  vagina,  between  the  surfaces,  and  changed  daily  until  the 
parts  are  healed.      This  will  not  only  prevent  adhesions  between 
the   cut  surfaces,   but  if  the  vagina  is  filled,  it  will  prevent  con- 
traction of  the  canal  from  cicatrization.      As  this  is  a  very  severe 
operation,   where   much   of  the   vagina  has  been  occluded,  great 
care  will  be  required  in  the  subsequent  treatment,  to  prevent  the 
inflammation  from  extending  to  the  adjoining  structures,  especially 
to    the   uterus   and   peritoneum  ;    to  prevent  this,  rest,    absolute 
quiet,    fomentations   to    the    vulva,    vaginal    injections    of    tepid 
water,  or  water  and  milk,  should   be   used   if  necessary,  and  if 
symptoms   of   metritis    or   peritonitis    should  present  themselves, 
they  must  be  treated  as  described  under  their  separate  heads. 

STRICTTRE    OF  THE  VAGINA. 

202.  Cases  in  which   the  vagina  is  much  smaller  than  natural 
lire  not  very  unfrequent ;  yet  those  cases  where  the  constriction 
is    so    great   as    to   come   under   the   care    of   the  physician   are 
uncommon.      Stricture  of  the  vagina  may  be  either  congenital,  or 
arise  in  some  part  of  the  canal  as  the  result  of  disease. 

203.  Congenital  stricture,  or  as  it  is  more  appropriately  named, 
narrowness  of  the  vagina,  is  very  seldom   seen.     Cases,  however, 
have  been  sometimes  met  with  where  the  deformity  has  prevented 
the  accomplishment  of  the  purposes  for  which  it  was  designed  by 
nature.     In  some  of  the  instances  that  have  been  met  with  the 
vagina  was  not  more  than  half  an  inch  in  diameter.     Prof.  Meigs 
reports  a  case   in   which   it  was   with   difficulty  that  the   vagina 
admitted  a  full  sized  bougie. 

204.  Acquired  stricture  of  the  vagina  is  much  more  frequent 
than   the    congenital;    it    may   result    from   violent    inflammation 
of  the  vagina,  producing  cohesion  of  some   part   of  its  wralls,  or 
from  any  cause  which  would  produce  thickening  and  induration  of 
its  walls,  as  the  imprudent  use  of  astringent  injections  in  vaginal 


114  DISEASES     OF     WOMEN. 

disease,  etc.  It  has  also  been  observed  to  follow  protracted  and 
difficult  labor,  accompanied  by  sloughing  of  some  portion  of  the 
vaginal  tissue. 

205.  Treatment. — The   treatment  of  this   difficulty,  whether  it 
be  congenital   or  acquired,  requires  patience  and  perseverance  to 
effect   a   cure.     The  means   to   be    made   use  of,   consists  in  the 
gradual  dilatation  of  the  stricture  by  means  of  graduated  bougies 
introduced   from    day  to   day,  or  what  would  be  better,  the    use 
of  two  hollow  half  cylinders   of  germ  an   silver,  which  should  be 
introduced  into  the  vagina,  thus  forming  a  cylinder ;  into  this  may 
be  pressed    a  conical  bougie  of  wood,  thus  producing  dilatation 
without  the  friction  attendant  on  introducing  the  bougies.     These 
wooden    dilators    may  be   increased   in   size  at    each  subsequent 
introduction  until  sufficient  dilatation  has  been  produced. 

206.  Should  there  be  an  indurated   condition  of  the  parts,  the 
walls  of  the  vagina  feeling  hard  and  resisting,  emollient  injections 
should  be  employed,  with  the  use  of  warm  topical-baths. 

207.  It  has    been   recommended   by   some    authors,   to   make 
shallow   incisions  in  the   vaginal  walls    to   assist  the  process  of 
dilatation.     This  I  consider  needless,  in  fact  injurious,  as  more  or 
less  inflammation  will  follow,  and  prevent  the  use  of  the  dilatators 
until  the  incisions  have   cicatrized.     The  knife  should  never  be 
employed  without  it  is  for  the   purpose  of  dividing  fibrous  bands 
which   pass    between  the   vaginal  walls,  or  where   the    stricture 
occupies  but  a  small  portion  of  the  canal. 

208.  As  these  cases  of  acquired  occlusion  and  stricture  of  the 
vagina  so  frequently  follow  protracted  labor,  or  where  instruments 
have  been  used,   when  followed  by  inflammation,  and   sloughing 
of  the    vaginal   walls,  we  should   never    forget   the    chances  of 
deformity  resulting,  and   should  use  such  means,  at  the  time,  as 
will  prevent  any  of  the  serious  consequences  just  described. 

209.  In  all  such  cases,  careful  examinations  should  be  made 
from  time  to  time,  to   ascertain   the  exact  nature  of  the   morbid 
processes.     At  first,  when  the  inflammation   is   acute,  emollient 
injections  should  be  used,  together  with  the  application  of  poultices 
and  fomentations   to  the  vulva,  and  such   other  measures  as  will 
suggest  themselves  to  the  mind  of  every  well-informed  practitioner. 


1  X  F  ].  A  M  M  A  T  I  ( )  X     ( )  I-'    T  1 1  K     A"  A  G  I  N  A.  ]  1 0 

As  .soon  as  the  inflammation  has  somewhat  subsided,  pledgets  of 
oiled-lint  should  he  introduced  between  the  ahraded  surfaces  to 
prevent  adhesions;  this  should  he  followed  as  soon  as  circumstances 
uill  admit,  by  a  roll  of  oiled-lint  sufficient  to  distend  the  vagina, 
and  prevent  any  contraction  that  might  take  place  from 
cicatrization. 

ACUTE  VAGINITIS— INFLAMMATION   OF  TIIM  VAGINA. 

210.  Inflammation   of  the  vagina   may  he   confined   entirely  to 
the  mucous  membrane,  or  it  may   affect  both   this  and  the   sub- 
mucous  cellular  tissue.      Acute  vaginitis   is    attended    with    pain, 
swelling   and   redness  of  the  vaginal  canal.      The  patient   feels  a 
sensation    of  heat    and   fullness   in   the    vagina ;    and  if  a   digital 
examination  be  made,  the  canal  is  found  swollen  and  tender  to  the 
touch.     On   bringing  the  vaginal  mucous  membrane  into  view  by 

O          O  Cj  «/ 

means  of  the  speculum,  should  the  pain  and  swelling  not  be  too 
great  to  admit  of  its  use,  it  is  found  of  a  vivid  red  color,  and  the 
rugre  appear  more  developed  and  prominent  than  in  the  normal 
state.  At  first  there  is  an  arrest  of  secretion,  as  in  the  first  stage 

'  O 

of  inflammation  in  mucous  membrane  generally  ;  but  after  a  day 
or  two,  more  or  less  abundant  secretion  sets  in,  at  first  serous,  and 
then  purulent,  and  of  a  yellowish  or  greenish  color.  As  soon  as 
this  secretion  is  fairly  established,  the  heat,  swelling,  fullness,  and 
pain  diminish  greatly.  The  development  of  these  local  symptoms 
is  seldom  accompanied  by  much  general  febrile  reaction,  unless 
the  sub-mucous  tissues  become  involved;  in  that  case  the  inflam- 
mation may  assume  a  phlegmonous  form,  and  terminate  in  puru- 
lent collections,  which  empty  into  the  vagina,  or  at  the  vulva. 
Instead  of  terminating  in  suppuration,  however,  it  most  generally 
leads  to  considerable  thickening  and  coriaceous  induration  of  the 
vaginal  parietes  ;  the  latter  at  the  same  time  becomes  less  movable, 
so  as  to  seem  agglutinated  to  the  adjoining  parts. 

211.  The  amount  of  fluid  secreted  by   the  inflamed  surfaces 
varies  greatly  ;  in  some  it  is  slight,  and  formed  by  a  mixture  of 
the  white  mucus,  secreted  in  the  upper  part  of  the  vagina,  and  of 
the  yellow  matter,  the  product  of  the  acute  inflammatory  action  ; 


116  DISEASES     OF    WOMEN. 

in  others  it  is  very  abundant,  thick,  and  of  a  yellow  or  greenish 
color. 

212.  Causes. — Acute  vaginitis  may  arise  from  cold,  which  is 
the  most  frequent  cause  ;  from  violence,  (as  in  rape,)  excessive 
sexual  indulgence,  exertion  soon  after  delivery,  high  living,  etc. 
The  sub-mucous  form  of  the  inflammation  arises  more  frequently 
from   injuries   of  the   vagina   or   parts   adjacent ;    after   delivery, 
either  in  protracted  labors  where  the  head  of  the  child  has  been 
long  in  passing,  pressing  upon  the  parts,  or  what  is  more  uncom- 
mon in  very  rapid  labors,  where  the  soft  parts  have  been  dilated 
very  rapidly. 

213.  Diagnosis. — It    becomes    of    great    importance    in    some 
cases  to   diagnose,   if  possible,   simple  vaginitis  from  gonorrhea. 
The  diagnosis  here  is  very  difficult,   if  not  impossible   in  many 
cases.     In  gonorrhea  there  is  nearly  always  a  greater  discharge 
from  the  urethra  than  in  simple  vaginitis ;  yet  this  is  not  positive, 
for  in  some  cases  gonorrhea  affects  the  urethra  but  very  slightly  ; 
not  as  much  as  in  some  cases  of  vaginitis,  where  the  inflammation 
extends  to  the  urethral  mucous  membrane,  in  consequence  of  the 
continuity  of  tissue,  involving  it  to  nearly  the  same  extent  as  the 
vagina.     Probably  the  observations  of  Donne,  if  they  are  borne 
out  by  future  investigations,  will  furnish  the  most  reliable  means 
of  diagnosis.     He  states  that  in  the  gonorrheal  discharge  there 
are  certain  animalcule,  which  may  be  detected  by  the  microscope, 
and  which   are   never  found  in   any   other   discharges  from   the 
vagina.     These  animalcule,  he  says,  may  be  recognized  by  the 
elongated  filliform  appendix  attached  to  their  bodies,  and  which 
may  be  seen  in  motion  if  the  discharge  is  recent.     Ricord  states, 
that  he  can  distinguish,  the  diseases  by  the  specific  character  of 
the  erosions  on  the  cervix  uteri.     The  glands  of  the  groin  are 
also  less  affected  in  simple  vaginitis  than  they  are  in  gonorrhea. 
After  all,  it  is  probable  that  the  character  of  the  patient  and  her 
husband  will  give  the  best  evidence  of  the  nature  of  the  disease. 
In  some  cases  where,  from  the  known  character  of  the  parties, 
there  could  not  be  the  slightest  suspicion  of  gonorrhea,  the  hus- 
band has  contracted  a  blennorrhea  from  connection  with  his  wife,* 


I  N  F  L  A  M  M  A  T  1  O  X     0  F     T  II  K     V  A  G  I  X  A .  117 

and  which  presented  all  the  characteristics  of  true  gonorrhea,  and 
•which  was  amenable  to  no  other  treatment  than  that  resorted  to 
for  that  disease.  Such  cases  as  these,  and  the  extreme  difficulty 
of  forming  a  diagnosis,  should  make  the  physician  very  careful 
how  he  expresses  an  opinion  in  regard  to  the  character  of  the 
disease,  even  if  he  should  be  convinced  in  his  own  mind  that  it 
was  gonorrhea. 

214.  Treatment.  —  The   consequences    of    an   attack  of  acute 
vaginitis  are  seldom  of  much  importance,  if  the  disease  is  treated 
in  time.     If  it  be  neglected,  narrowing  of  the  vagina,  or  adhesion 
of  its  sides  may  possibly  take  place,   but  if  discovered  in  time, 
they  are  easily  remedied.     If  much  constitutional  disturbance  be 
present,  the  special  sedatives,  with  such  other  remedy  as  may  be 
indicated,  should  be  given  and  continued  until  the  inflammation 
is  arrested.     Especial   attention   is  called  to  Ehus  when  there  is 
burning  pain  and  acrid  discharges  ;  Macrotys  when  there  is  deep 
tensive  pain   in  back  and   hips;  Viburnum  when  the  pains  are 
pressing  down;  Apis  when  there  is  itching  and  burning;  Pulsa- 
tilla  when  the  patient  is  depressed  and  nervous  ;  Belladonna  when 
there  is  incontinence  of  urine ;  Santonine  when  there  is  partial 
or  complete  retention,  etc. 

215.  As  local  appliances  in  the  acute  stage,  fomentations  of 
Stramonium  or  the  flowers  of  Arnica,  applied  over  the  vulva,  will 
give  great  relief;  in  connection  with  this,  vaginal  injections  of 
warm   water,   or  what  is  better,  of  a  decoction  of  Stramonium, 
should  be  used  every  few  hours.     A  warm  hip-bath,  occasionally, 
will  also  be  found  a  powerful  adjunct  in  abating  the  inflammation. 

216.  If  there  be  constipation   of   the  bowels,  they  should  be 
moved  as  often  as  once  a  day ;  any  agent  that  is  preferred  may 
be  used  for  this  purpose.     As  soon  as  the  acute  symptoms  have 
been   subdued,  if  there  is   still  a  discharge,  accompanied  with  a 
lax  condition  of  the  vaginal  mucous  membrane,  an  injection  of 
Salicylic    Acid    and   powdered   Borax    should    be  used    to    give 
strength  and  tone  to  the   organs,  and  prevent  the  disease  from 
running  into  the  chronic  form.     The  decoction  of  these  articles 
should  be  made  of  such  strength  as  will  suit  the  case  on  hand. 

217.  In  the  majority  of  cases,  if  these  means  be  made  use  of  in 


118  DISEASES      OF      WOMEN. 

the  early  stage  of  the  disease,  a  perfect  cure  will  result ;  if  not, 
in  all  probability  it  will  assume  the  chronic  form. 

CHRONIC  VAGIXITIS — VAGINAL  LEUCORRHEA. 

218.  This   is   one  of  the   most  common  diseases  to  which  the 
female  is  subject ;  very  few,   indeed,   escaping  attacks   of  it,  at 
some  period  of  their  lives  ;  and  this  is  not  surprising,  when  we 
consider   the   many  causes   of   imtation   to   which  this  canal  is 
subject. 

219.  Chi'onic   vaginitis   is  an  important  disease,   not  only  on 
account  of  the  extreme  loss  of  fluids  which  it  often  entails,  but 
also  on  account  of  its  constant  tendency  to  extend  to  the  uterus 
and  the  fallopian  tubes,  and  the  consequent  morbid  affections  of 
these  organs.     It  predisposes  to  intussusception   of  the  vagina, 
and  the  displacement  of  the  uterus,  owing   to  the  relaxation  it 
induces  ;  it  leads  to  excoriation  and  superficial  ulceration,  both 
of  the  vagina,  the  external  pudenda,  the  parts  in  their  vicinity, 
and  of  the  cervix  uteri,  to  closure  of  the  os  tincae,  to  follicular 
suppuration,  permanent  hypertrophy  of  the  follicles,  and  dilata- 
tion of  the  vaginal  vessels. 

220.  This  disease  may  be  general  or  partial ;  it  may  continue 
indefinitely,   for   years,   like  chronic    inflammation   of    all    other 
mucous  membranes,  giving  rise  to  a  constant  secretion   of  mucus 
or  muco-purulent   fluid,  and   varying   in    intensity  according  to 
the  epoch  of  the  month,  and  to  the  state  of  the  health  and  social 
and  hygienic  position  of  the  patient.     In  the  course  of  time,  it 
often  passes  into  a  mere  mucoso-purulent  flux.     Its  existence,  in 
this  chronic  form,  is  a  source  of  general  debility  and  weakness, 
but  by  no  means  to  the  extent  supposed  by  some  authors;  the 
sympathetic  connection  between  the  vagina  and  the  rest  of  the 
economy  being  slight,    when    compared   with    that   which    exists 
between    the    uterus    and   the    system  in  general.     "  When   the 
health   of    a   patient,   laboring    under    chronic    vaginitis,    suffers 
greatly,   it  will    be   found,  on    examination,   that   there    is    also 
disease  of  the  neck  or  body  of  the  uterus  or  of  the  ovaries." 

221.  Symptoms. — The   symptoms  of    this  disease   are   a   dis- 
charge from  the  vagina,  sometimes  thin  and  colorless,  but  more 


VAGIXAL     LKUCOKKHEA.  119 

frequently  white,  or  of  a  slightly  yellowish  cast  ;  as  the  disease 
piogiesses  it  becomes  muco-purulent,  and  varies  in  color  from  a 
slightly  yellowish  white  to  a  brownish  cast.  In  the  majority  of 
cases,  the  discharge  is  of  a  bland  character,  producing  no  exco- 
riatioh  or  other  difficulty  ;  yet  in  some  few  cases  it  becomes  very 
acrid,  excoriating  the  vulva  and  other  parts  with  which  it  comes 
in  contact,  and  producing  in  the  male  all  the  symptoms  of 
gonorrhea,  and  sometimes  ulceration  of  the  prepuce.  There  is 
scarcely  ever  tin  increase  of  heat  in  the  parts,  and  seldom  any 
pain  or  tenderness.  So  long  as  the  disease  is  confined  to  the 
vagina,  there  is  very  little  constitutional  disturbance,  though  if 
the  discharge  is  profuse,  and  has  continued  for  some  time,  there 
may  be  considerable  weakness,  with  pain  in  the  back  and  loins, 
loss  of  appetite,  constipation,  etc. 

222.  Upon   examination    with    the   speculum,    the   vagina    will 
appear  flabby,  its  mucous  membrane  tumefied  and  pale,  invested 
with  a    pale   thick  coating  of    epithelium,  or  excoriated  or  red- 
dened, with  enlargement  of  the  follicles,  which  are  surrounded  by 
a  vascular  ring.     Or  the  follicles  may  be  found  ulcerated,  forming 
gmall  apthous  sores  ;  these,  however,  are  generally  limited  to  the 
lower  portion  of  the  vagina.     The  continuance  of  the  morbid  pro 
cess  to  the  cervix  uteri,  and  to  the  lining  membrane  of  the  uterus, 
will  be  considered  in  the  chapter  on  leucorrhea. 

223.  Diagnosis. — The    diagnosis    between    this    disease    and 
gonorrhea  will  have  to  be  made — if  made  at  all — in  the  manner 
described  when  treating  of  acute  vaginitis.     It  may  generally  be 
distinguished    from    uterine    leucorrhea,   by  the   discharge    being 
unconnected  with  uterine  irritation,  by  its  not  increasing  before 
and    after  menstruation,  by   the   minor   degree    of  constitutional 
suffering,  and  by  the  acrid  character  of  the  secretion  in  vaginitis, 
which  reddens  litmus,  while  the  uterine  discharge  has  aft  alkaline 
reaction.     In    many    cases,    however,    and    especially    where  the 
leucorrhea    has    continued    for    some   time,   the   uterine    mucous 
membrane  w7ill  be  found  more  or  less  affected. 

224.  Causes. — The    causes    producing   vaginal    leucorrhea    are 
various.     Thus  it  may  result  from  an  acute   attack  of  vaginitis  • 
from  exposure  to  cold  and  moisture  when  the  system  is  enfeebled 


120  DISEASES     OF     WOMEN. 

excessive  sexual  indulgence  ;  frequent  child-bearing  ;  abortions, 
from  which  the  patient  has  only  partially  recovered  ;  the  irritation 
of  a  pessary,  or  stimulant  injections  into  the  vagina  ;  displacements, 
morbid  growths,  etc.  There  is  one  cause  of  chronic  vaginitis 
that  is  very  rarely  referred  to,  which  not  only  produces  the 
disease  in  some  cases,  but  which  also  prevents  a  perfect  cure  in 
many  others  ;  this  cause  is  functional  or  structural  disease  of  the 
rectum.  It  has  doubtless  been  noticed  by  every  practitioner,  how 
intractable  those  cases  of  leucorrhea  are  in  persons  subject  to 
piles,  to  habitual  constipation,  with  accumulated  freces  in  the 
rectum,  fissure  of  the  rectum,  etc.  In  these  cases,  the  cause  of 
the  difficulty  should  be  first  removed  before  attempting  any 
specific  treatment  for  the  vaginitis. 

225.  Treatment. — Much  has  been  written  on  the  treatment  of 
leucorrhea,  yet  very  few  authors  make  any  distinction  in  recom- 
mending remedies,  in  regard  to  the  part  from  which  the  discharge 
proceeds,  or  the  conditions  present  producing  it.     As  I  will  give, 
under  the  head  of  leucorrhea,   a  full  description  of  the  various 
causes  producing  a  discharge  from  the  genital  organs,  together 
with   the  treatment  appropriate  to  each,  I   will   confine  myself 
here  to  the  treatment  of  chronic  vaginitis,  independent  of  other 
affections. 

226.  The  treatment  in  this  affection  consists  in  the  use  of  both 
general   and  topical  medication.     The  general  treatment  in  the 
first  place,  should  be  directed  to  obtain  a  healthy  performance  of 
all  the  functions  of  the  system ;  should  the  patient  be  debilitated, 
the  vegetable  tonics  and  iron  will  be  required ;  should  there  be 
torpor  of  the   skin,  kidneys,  or  bowels,  these  organs  should  be 
stimulated  to  a  normal  performance  of  their  functions.     This  will 
be  found  to  be  of  the  utmost  importance,  not  only  in  this  disease, 
but  in  al!  others   accompanied  with  a  chronic  discharge ;  for  in 
these  cases,  it  might  be  said  with  truth,  that  the  diseased  organ  is 
performing  a  vicarious  secretion,  which  prevents  the  normal  action 
of  the  proper  excretory  organs,  and,  to  subdue  the  diseased  action, 
it  will  first  be  necessary  to  provide  for  this  elimination  through 
the  natural  channels. 

227.  In  the  second  place,  general  remedies  are  employed  to 


VAGINAL    LEU  CO  R  R  HCE  A.  121 

remove  the  local  inflammation,  and  cheek  the  morbid  action  of 
the  parts.  For  this  purpose  man}'  remedies  have  been  used,  but 
to  have  success  the  remedies  must  ho  selected  with  reference  to 
the  special  case  in  hand.  Any  of  the  remedies  named  for  acute 
vaginitis  may  he  required,  the  indications  there  given  being  suffi- 
cient to  call  for  them  here.  In  some  cases  characterized  by  more 
or  less  uterine  pain,  pain  in  the  back  and  thighs,  the  use  of  Ma- 
cro tys  with  Pulsatilla  will  give  good  results.  The  case  with  sen- 
sations of  fullness  and  weight,  dragging  in  the  pelvis,  etc.,  may 
be  met  by  Hamamelis  and  Viburnum.  When  associated  with 
passive  hemorrhage,  the  flow  prolonged,  recurring  too  frequently, 
with  pallid  transparent  skin,  it  is  met  with  Carbo  veg.,  2d  decimal 
trituration  ;  and  blood-making  is  promoted  by  the  administration 
of  tincture  of  Copper.  Again,  we  have  cases  benefited  by  the  use 
of  iron — tincture  of  the  Muriate  when  the  tongue  is  deep  red, 
iron  by  hydrogen  when  it  is  pallid.  Phosphorus  is  indicated  by 
impaired  innervation,  or  if  we  regard  the  condition  of  the  parts, 
full,  relaxed  and  pallid.  Want  of  sexual  power  or  appetite  is 
remedied  by  the  use  of  Iodine  and  Nux,  as  in  the  Compound 
Iodine  Pill  (Iodine,  Ext.  Nux,  aa.  gr.  vj;  Hydrastin,  grs.  xxx.; 
make  thirty  pills.) 

As  an  injection  I  like  a  solution  of  Chlorate  of  Potash  for  the 
simple  cases  (3ij.  to  water  Oj.),  with  the  addition  of  a  small  por- 
tion of  Sulphate  of  Zinc,  if  the  discharge  is  markedly  purulent. 
Salicylic  Acid  and  Borax  (aa.  gij.  to  water  Oj.)  is  a  most  excellent 
injection,  as  is  a  solution  of  Phosphate  or  Sulphate  of  Hydrastia, 
{gr.  ij.  to  water  5J.) 

In  addition  to  these  a  large  number  of  the  vegetable  tonics 
.and  astringents  have  been  used  with  good  success.  Among 
these  I  may  name  the  Hamamelis,  and  the  Rumex  Crispus  with 
Quercus. 

Some  of  our  practitioners  use  the  Hydrastis  Canadensis  in  con- 
bination  with  the  Statice  Limonum,  the  Rhus  Glabrum,  or  the 
Rubus  Villosus ;  either  of  which,  answer  an  admirable  purpose ; 
not  alone  from  their  astringent  propei'ties,  but  also  from  their 
tonic  effect  on  the  mucous  membrane.  In  some  cases,  where 
there  is  a  lax  and  flabby  condition  of  the  mucous  membrane,  with 
dilatation  of  the  vessels,  hypertrophy  of  the  follicles,  or  ulcera- 


122  DISEASES     OF    WOMEN 

tion,  an  injection  of  the  Sulphate  of  Zinc  (3j.  to  gvj.  of  water,) 
may  be  used  with  much  benefit.  Still  I  would  prefer  the  Sali- 
cylic Acid  and  Borax,  as  recommended  in  the  first  prescription, 
increasing  the  quantity  as  the  patient  could  bear  it,  until  the 
difficulties  were  removed. 

229.  These  injections  should  be  used  with  a  female  syringe, 
the  patient  being  in  a  horizontal  position,  with  the  hips  elevated. 
As  soon  as  the  injection  is  thrown   in,  the  external  parts  should 
be  compressed  with  a  napkin,  thus  retaining  the  injection  in  con- 
tact with  the  vaginal  walls,  for  ten  or  fifteen  minutes.     Without 
these  directions  are  given,  the  patient  will,  in  all  probability,  use 
the  syringe  in  a  standing  or  sitting  posture,  letting  the  injection 
immediately  pass  away ;  in  these  instances,  the  physician  may  be 
surprised,  that  remedies  which  he  places  great  confidence  in,  have 
produced  but  little  effect,  yet,  upon  inquiry,  the  difficulty  will  be 
found  entirely  in  the  mode  in  which  they  are  used. 

230.  The  treatment  after  the  vaginitis  has  been   subdued,  and 
the  discharge  stopped,  deserves  careful  attention,  for  it  is  prob- 
able that  there  is  no  morbid  condition  of  the  system   so  likely  to 
recur  as  this ;  if  the  cause  of  the  affection  be  known,  the  patient 
should  be  cautioned  against  exposing  herself  to  it.     Strict  atten- 
tion to  cleanliness  should  be  enjoined,  and  that  unfounded  dread 
of  water,  which  most  females  have,  should   be  removed,  if  pos- 
sible.      After  an    attack  of    this  disease,  the  patient   should    be 
directed  to  use  vaginal  injections  of  cold  water,   at  least  once  a 
day ;  and  if  there  should  be  a  tenacious  secretion  from  the  parts, 
a  little  Castile  soap  will  not  be  amiss.     This  will  insure  perfect 
cleanliness,  and  give  tone  and  strength  to  the  genital  organs,  and 
prove  a  perfect  prophylactic  against  any  future  attack. 

PROLAPSE  OF  THE  VAGINA. 

231.  This  affection  is  not  uncommon,  and  has  very  often  been 
taken  for  prolapsus  uteri.     It  generally  occurs  in   females  who 
have  borne  children,  and  who  have  passed  the  middle  age,  though 
in  some  few  instances,  it  has  been  observed  in  the  young,  and 
before  marriage.     We  distinguish  three  varieties  of  this  affection 
each  of  which  derives  its  importance  from    the  displacement  of 


VAGINAL      CYSTOCELE.  123 

the  viscera  connected  with  the  vagina.  First,  prolapse  of  the 
anterior  wall  of  the  vagina,  and  of  the  bladder  which  lies  upon 
and  is  closely  connected  with  it.  This  has  received  the  name  of 
'•  Prolapsus  Vesicie,"  or ''Vaginal  Cystocele."  Second,  prolapse 
of  the  posterior  wall,  accompanied  by  the  rectum,  called  "Vaginal 
Rectocele."  Third,  prolapse  of  the  entire  circumference  of  the 
vaginal  canal. 

VAGINAL  CYSTOCELE. 

232.  This  is  the  most  common  form  of  vaginal  prolapsus,  and 
may  arise  from  any  cause  which  has  a  tendency  to  weaken  and 
relax  the  vaginal  walls  ;  such  as  repeated  child-bearing,  difficult 
labors,  etc.     This  relaxation  of  the  vaginal  wall  causes  an  altera- 
tion in  the  position  of  the  bladder,  and,  in  consequence  of  this, 
there  is  retention  of  urine,  which,  distending  the  bladder,  forces 
it  downward  into  the  vagina.     The  more  the  bladder  is  displaced, 
the  greater  will  be  the  difficulty  in  evacuating  the  urine,  owing  to 
the  backward  curvature  of  the  urethra ;  and,  in  consequence  of 
this,  there  will  be  accumulations  in  the  bladder,  by  the  weight  of 
which  the  vagina  is  stretched  still  further,  and  thrust  downward 
and  forward ;  if  this  continues,  complete  prolapse  or  protrusion 
through  the  external  parts  will  be  the  result. 

233.  Symptoms. — The  patient  complains  of  a  constant  weight 
and  pressing  clown  into  the  vagina,  a  sensation  of  uneasiness  and 
dragging  down  in  the  lower  portion  of  the  abdomen ;  uneasiness 
and  pain  in  walking ;  great  difficulty  in  evacuating  the  bladder, 
which  sometimes  amounts  to  almost  complete  dysuria, — the  bladder 
becoming  paralyzed  from  retention  of  urine,  and  losing  its  power 
of  contraction  ;  in  some  cases,  the  patients  are  obliged  to  replace 
the  bladder  before  they  can  complete  the  evacuation.     In  many 
cases,  the  patients  will  complain  of  a  burning  pain  in  the  base  of 
the  bladder,  with  a  sensation  of  distention,  and   a  constant   and 
torturing  desire  to   pass  urine.     On   examination,  there  will   be 
found  a  round,  soft,  elastic,  fluctuating  tumor,  of  a  red  or  bluish- 
red  color,  and  which  is  covered  by  the  mucous  membrane  of  the 
vagina ;  the  finger  can  be  passed  into  the  vagina  below  the  tumor, 
and  the  os  uteri  can  be  felt  behind,  nearly  in  its  normal  position. 
The  surface  of  tfye  tumor  is  smooth  and  shining  when  the  bladder 


124  DISEASES     OF     WOMEN. 

is  distended  ;  but,  when  the  bladder  is  empty,  it  is  thrown  into 
transverse  folds.  A  very  unpleasant  consequence  of  this  displace- 
ment has  been  pointed  out  by  Dr.  Golding  Bird.  This  consists 
in  a  chronic  inflammation  of  the  bladder,  caused  bv  the  retention 
of  urine,  and,  under  the  influence  of  this  chronic  inflammation,  the 
mucous  membrane  of  the  bladder  secretes  so  much  of  the  earthy 
phosphates,  and  unhealthy  mucus,  as  to  render  the  urine  puriform 
and  offensive.  Often  there  is  a  very  considerable  mucous  dis- 
charge from  the  vagina,  which  is  exceedingly  irritatin^  to  the 

O    «/  O 

labia  and  soft  parts. 

234.  Diagnosis. — This    affection    may    be    readily    diagnosed 
from  any  displacement  of  the  uterus,  if  the  following  points  are 
regarded.     The  tumor  formed  by  prolapse  of  the  bladder,  varies 
in  size  according  to  the  quantity  of  urine  retained;  it  may  be 
decreased  somewhat  by  drawing  off  the  urine  with  the  catheter; 
and  if  the  extremity  of  the  catheter  is  elevated,  its  point  may  be  felt 
in  the  most  depending  portion  of  the  tumor.    The  tumor  is  soft  and 
fluctuating,  and  the  finger  can  be  passed  posteriorly  to  it  up  to  the 
os  uteri,  which  will  be  found  in  its  natural  position.     It  may  be 
distinguished  from  vaginal  rectocele,  by  the  fact  that  it  is  softer 
and  fluctuating,  and  the  finger  passes  into  the  vagina,  posteriorly 
to  it,  while  in  rectocele  it  can  only  be  introduced  anteriorly. 

235.  Treatment. — The    treatment    of    this    disease    will    vary 
much,  according  to  the  state  of  the  parts,  and  the  length  of  time 
the  difficulty  has  existed.     The  indications  to  be  regarded,  are, 
first,  to  give   temporary  relief  by  emptying  and  replacing  the 
bladder,  using  some   mechanical  means   to   keep  it  in  position ; 
secondly,  to  correct  the  secretions,  and  subdue  any  inflammatory 
action  that  may  be  going  on  in  the  bladder ;  and,  thirdly,  to  use 
such  means  as  will  produce  a  radical  cure  of  the  difficulty. 

236.  To  fulfill  the  first  indication,  the  urine  should  be  drawn 
off  with    the    catheter,   elevating   the    depressed    portion  of  the 
bladder,  so  as  to  remove  it  entirely,  or  if  the  patient  can  empty 
the  bladder  herself  without  the  use  of  the   catheter,  it  will  be 
better.     The  main  point  should  be  to  entirely  empty  the  bladder, 
leaving  no  urine  in  the  prolapsed  part,  to  keep  up  irritation ;  this 
should  be  done  very  frequently.     The   prolapsus  may  be  very 


VACIXAL     C  VSTOCELE.  125 

easily  returned  when  the  bladder  is  empty.  To  retain  it  in  its 
position,  a  small  India  Rubber  bag,  inflated  with  air,  and  retained 
with  a  perinea!  bandage,  will  be  found  to  be  much  better  than  any 
of  the  hard  pessaries  recommended.  This,  by  being  elastic,  molds 
itself  to  the  parts,  admits  of  perfect  freedom  of  motion  without 
pain  or  inconvenience ;  produces  but  very  little,  if  any  irritation, 
and  does  not  produce  dilatation  of  the  canal,  and  yet  furnishes  a 
perfect  support  to  the  bladder.  This  pessary  should  be  removed 
twice  a  day  and  cleaned,  a  vaginal  injection  of  a  decoction  of 
Hydrastis  Canadensis,  llubus  Villosus,  and  Statice  Limonum, 
equal  parts  (3j  to  Oct  j  of  water)  should  be  used  at  these  times. 
With  this  treatment,  if  the  irritation  of  the  bladder  has  been  sub- 
dued, as  I  have  recommended  below,  many  cases,  especially  those 
of  recent  date,  can  be  perfectly  cured. 

237.  The  irritation  or  low  degree  of  inflammation  of  the  bladder, 
that  often  exists,  will  be  found  to  be  one  of  the  most  troublesome 
complications  of  this  disease,  and  without  this  is  removed,  a 
permanent  cure  is  impossible.  I  have  already  st-ated  that  the 
bladder  should  be  frequently  and  entirely  evacuated,  to  prevent  the 
irritation  which  the  retained  and  decomposing  urine  would  produce, 
as  well  as  to  remove  the  weight  which  was  continually  pressing 
upon  the  relaxed  walls  of  the  vagina ;  this  point  in  the  treatment 
is  so  important  that  it  will  bear  repetition.  To  subdue  the  irrita- 
tion and  give  tone  to  the  mucous  membrane  of  the  bladder,  I 
would  recommend  the  muriated  tincture  of  Iron  and  the  Eryng- 
ium  given  in  the  usual  doses.  If  the  urine  should  become 
muco-purulent  and  fetid,  the  following  injection  should  be  thrown 
into  the  bladder. 

R  Hydrastis  Canadensis,  Sj. 
Aqua  Bullientis,  Oct  j. 

Let  it  stand  until  it  is  cold,  then  strain  and  inject  one-third  of  it 
into  the  bladder  once  a  day.  This  may  increase  the  irritation  in 
some  cases  the  first  few  times  that  it  is  used ;  if  it  does,  its  use 
should  be  suspended  for  three  or  four  days  until  the  irritation  has 
subsided,  and  then  commence  its  use  again.  If  there  is  mucus 
secreted  of  a  ropy  or  fetid  character,  it  will  be  well  to  alternate 


126  DISEASES     OF      WOMEN. 

this  injection  with  one  of  an  acid  character,  as  distilled  Vinegar 
Sss  to  oct  j  of  water ;  of  this,  one  or  two  ounces  should  be  used 
at  each  injection.  Dr.  Newton  informs  me  that  he  has  used  with 
much  success,  an  injection  of  Glycerine,  throwing  into  the  bladder 
from  half  an  ounce  to  an  ounce  through  a  catheter.  This  forms  a 
very  soothing  and  healing  application  to  the  inflamed  bladder. 

238.  In  all  recent  cases,  and  indeed  in  some  of  long  standing, 
the  measures  above  recommended  will  effect  a  permanent  cure  if 
the  general  health  lie  good,  but  there  are  some  in  which  they  will 
give  but  temporary  relief.  In  these  cases  there  will  be  found 
great  laxity  of  the  tissues,  ;i  flabby  and  dilated  state  of  the  vagina, 
weakness  of  the  perineal  muscles,  and  often  an  enlarged  pelvis, 
and  extreme  thinness  of  the  perineum.  Different  measures  have 
been  recommended  in  these  cases  to  remove  the  difficulty.  Some 
have  recommended  plugging  the  vagina  with  pessaries,  made 
especially  for  that  purpose ;  others,  the  introduction  of  a  soft 
sponge,  cut  in  the  furm  of  a  pessary,  and  saturated  with  some 
astringent  solution  ;  or  a  sack  made  of  soft  cotton  or  linen  cloth 
in  the  form  of  a  pessary,  and  filled  with  some  astringent  substance. 
It  is  certainly  obvious  that  these  measures  will  do  no  more  than 
give  temporary  relief,  while  they  are  very  liable  to  produce  irrita- 
tion, and  by  keeping  the  vagina  distended  ultimately  increase  the 
diseased  condition.  Other  authors  recommend  surgical  measures 
to  decrease  the  size  of  the  vagina,  and  thus  relieve  the  difficulty. 
M.  Jobert,  of  Paris,  incloses  within  two  curved  lines  an  oval 
space,  more  or  less  considerable  in  the  posterior  surface  of  the 
tumor,  or  the  anterior  surface  of  the  vagina,  by  means  of  caustic, 
until  it  forms  an  isolated  spot,  repeating  the  application  of  the 
caustic  until  the  mucous  membrane  is  destroyed.  He  then  pares 
the  edges  with  scissors  or  a  bistoury,  draws  them  together  and 
maintains  them  in  apposition  by  means  of  straight  needles  (the 
points  of  which  are  removed )  and  a  twisted  suture.  This  opera- 
tion consists  in  contracting  the  anterior  wall  of  the  vagina  and 

O  73 

thus  forming  a  support  to  the  bladder.     He  reports  the  operation 
as  successful  in  three  cases. 

239.    There  can  be  no  doubt  but  that  this  operation  would  prove 
successful  in  those  cases  where  the  difficulty  depended  on  a  lax 


Y  A  G  I  X  A  I,     C  Y  S  T  O  C  E  L  E  . 


127 


and  dilated  condition  of  the  vagina  ;  but  where  it  was  dependent 
on  weakness  of  the  perineum,  it  would  probably  fail.  The  opera- 
tion of  Mr.  Baker  Brown  appears  to  me  to  fulfill  all  the  indica- 
tions of  the  case.  He  operates  for  this  difficulty  in  the  same 
manner  that  he  docs  for  ruptured  perineum;  dissecting  off  a  longi 
tudinal  slip  of  mucous  membrane,  about  an  inch  and  a  quarter 


FIG.  12. — OPERATION-  FOR  PROLAPSE  OF  THE  VAGINA. 

long  and  three  quarters  of  an  inch  broad,  just  within  the  lips  of 
the  vagina  ;  the  upper  edge  of  the  denuded  part  being  on  a  level 
with  the  meatus  urinarius.  The  edges  of  the  mucous  membrane 
are  then  brought  together  by  means  of  interrupted  sutures.  He 
then  dissects  the  mucous  membrane  from  the  posterior  portion  of 
the  vaginal  orifice,  and  brings  the  denuded  parts  together  by 
means  of  the  suture.  (For  further  particulars  of  this  operation 
see  ruptured  perineum.)  By  these  means  the  vagina  is  not  only 
contracted  above,  but  the  perineum  is  greatly  increased  in  thick- 
ness and  strength,  forming  a  firm  support  to  the  pelvic  viscera. 


128 


DISEASES     OF     AVOMEX. 


FIG.  13. — CONDITION  OF  THE  PARTS  AFTER  THE  OPERATION  is  COMPLETED. 

Prolapse  of  the  bladder  may  occur  during  parturition,  and  may 
attain  such  a  size  as  to  prevent  delivery  of  the  child.  This  has 
occurred  in  several  instances,  in  some  two  or  three  cases  of  which, 
the  bladder  was  ruptured  in  consequence  of  the  pressure  of  the 
child's  head  against  it.  In  these  cases  the  bladder  must  be 
emptied  by  the  catheter,  and  then  replaced;  it  will  be  found 
impossible,  in  the  majority  of  cases,  to  introduce  the  common  silver 
instrument,  owing  to  the  great  degree  of  curvature  of  the  urethra, 
and  a  gum-elastic  catheter  should  be  used  in  its  stead.  If  the 
bladder  can  not  be  evacuated  by  the  catheter,  the  most  depending 
portion  of  the  tumor  will  have  to  be  punctured  with  a  trocar,  and 
the  bladder  emptied  through  the  canula. 

VAGINAL  RECTOCELE. 

240.  Prolapse  of  the  posterior  wall  of  the  vagina  is  not  of  as 
frequent  occurrence  as  prolapse  of  the  anterior ;  yet  it  can  not  be 


VAGIXAL     KECTOCELE.  129 

culled  an  unfrequent  affection.  The  mechanism  of  this  displace- 
ment is  similar  to  that  of  vaginal  cystocele;  the  posterior  wall  of 
the  vagina  becoming  relaxed,  the  rectum  is  distended  with  faeces 
and  pressed  anteriorly  and  downward  into  the  vaginal  canal.  The 
size  of  the  tumor  varies,  from  a  slight  projection  into  the  vagina, 
to  the  extension  of  it  into  a  tumor  projecting  between  the  labia 
In  its  more  aggravated  form  the  uterus  is  generally  involved  with 
it,  being  dragged  downward  and  displaced. 

241.  Cannes. — The    principal    cause    of    this    displacement    is 
habitual   constipation,  giving  rise  to   a  constant  accumulation  in, 
arid    distentiori    of   the    rectum.     This    undue   stretching    of   the 
rectum,  by  local  accumulations,  brings   about  a  relaxed  and  loose 
condition  of  its  tissues  ;   and  the  same  cause  stretching  the  parie- 
ties  of  the  vagina,  produces  a  looseness   of  that    canal.      This   is 
greatly  increased  by  the  use   of  drastic  cathartics  so   often  taken 
in    these   cases.     It  may   also   be  occasioned   by   an  enlarged  or 
displaced  uterus,  which  by  its  pressure  upon  the  rectum,  prevents 
its  evacuation  and  consequently  gives  rise  to  fecal  accumulations, 
and   distension   of  the  rectal  and  vaginal   walls.     It  may  also  be 
caused  by  an  entire  or  partial  rupture  of  the  perineum,  the  sphinc- 
ter muscle  remaining  entire.     In  these  cases  the  rectum  has  lost  its 
support  anteriorly  ;  there  riot  being  sufficient  power  in  the  peri- 
neum to  antagonize  the  action  of  the  sphincter,  the  anterior  part 
of  the  rectum  is  forced  into  the  vagina  until  it  meets  with  sufficient 
resistance  .to  overcome  this  contraction. 

242.  Si/mptoins. — The  general  symptoms  are  much  the  same 
as  in   the  other  variety   of   prolapse,   weight  in    the   vagina,    an 
uneasy  and  dragging  sensation  in   the  abdomen,  uneasiness  and 
pain   in   walking,  habitual  constipation   with   difficulty  in  passing 
the  fteces,  a  mncous  discharge  from  the  vagina,  etc.     If  there  is 
much  displacement,  there  will  be  tenesmus,  with  a  frequent  desire 
to  evacuate  the  bowels,  generally  fruitless  and  accompanied  with 
much  pain.     It  will  be  noticed  that  the   tumor  increases  in  size 
when  the  faeces  have  not  been  passed  for  some  time,  and   during 
defecation,  and  that  it  decreases  in  size  after  this. 

243.  On  making  an  examination,  a  globular  tumor  will  be  found 
occupying  the  cavity  of  the  vagina,  compressible  but  not  fluctuat- 

9 


130  DISEASES    OF    WOMEN. 

ing,  and  through  the  walls  of  which  scybala?  may  often  be  felt. 
By  passing  the  finger  over  the  tumor,  it  will  be  found  to  be 
covered  by  the  mucous  membrane  of  the  vagina,  and  that  the 
finger  can  be  passed  anterior  to  it,  up  to  the  cervix  uteri.  By 
making  an  examination  per  rectum,  the  finger  can  be  passed  into 
the  tumor  so  as  to  be  felt  at  its  projecting  part  in  the  vagina. 

244.  Diagnosis. — From  what  I  have  stated  above,  I  should  not 
suppose  it  possible  that  there  could  be  a  mistake  in  the  diagnosis, 
yet  it  can  do  no  harm  to  repeat.     This  may  be  diagnosed  from 
vaginal  cystocele,  by  its  greater  hardness,  and  the  absence  of  fluc- 
tuation, from  the  fact  that  the  finger  passes  anterior  to  it  in  the 
vagina,  and  that  it  diminishes  after  fecal  evacuations.     From  any 
displacement  of  the  uterus,  by  the  results  of  a  rectal  examination, 
by  the  variable  size  of  the  tumor  owing  to  retention  or  evacuation 
of  the  faeces,  and  by  the  fact  that  the  finger  can  be  passed  above 
it,  so  as  to  discover  the  os  uteri  in  situ. 

245.  Treatment. — The  treatment  of  this  variety  of  vaginal  pro- 
lapse   should   be    the    same   as  that  recommended   for   the  first 
variety,  so  far  as  the  local  applications  to  the  vagina  are  con- 
cerned, the  same  kind  of  a  pessary,  as  there  recommended,  will 
be  found  to  be  well  suited  to  these  cases ;  the  perineal  bandage, 
however,  should  be  so  applied  as  to  furnish  a  constant  and  efficient 
support  to  the  perineum. 

246.  If  a  cure   is   effected  in  these   cases  without  a  surgical 
operation,  it  will  have  to  be  accomplished  by  strict  attention  to 
the  state  of  the  rectum.     Constipation  of  the  bowels  being  the 
producing  cause  in  the  majority  of  cases,  and  which,  as  long  as  it 
remains,  will  prevent  any  permanent  improvement.     This  may  be 
overcome  by  the  use  of  injections  and  mild  laxatives  ;  all  cathar- 
tics of  a  drastic  character  should  be  sedulously  avoided.     After 
the  bowels  have  been  evacuated  by  an  injection,  much  benefit  may 
be  derived  from  a  second  injection  into  it  of  the  astringent  decoc- 
tion used  for  the  vagina. 

247.  In  all  cases  of  this  disease  it  will  be  proper  to  make  an 
examination    of  the    rectum,    to    ascertain  the  condition   of  the 
mucous  membrane,  and  whether  any  structural  lesions  exist,  as 
hemorrhoids,  fissures,   ulceration,   and  especially,  whether   it   is 


r  R  0  LA  P  S  E     0  F     T  11  K    VAG  I  X  A  .  131 

compressed  by  an  enlarged  or  displaced  uterus.  If  eitlier  of 
these  complications  exist,  they  will  have  to  be  removed  by  appro- 
priate treatment. 

248.  In  the  early  stage  of  the  disease,  or  where  the  prolapse 
is  not  large,  this  treatment,  if  perseveringly  pursued,  will  gener- 
ally give  permanent  relief.     But  where  the  prolapse  has  existed 
for  some  time,  attended  with  great  laxity  of  the  tissues,  and  defi- 
cient  strength    of   the    perineum,   recourse   to   surgical    measures 
should  not  be  delayed.     The  object  of  an  operation  in  these  cases 
is  to  increase  the  thickness  of  the  perineum,  and  thereby  enable  it 
to  resist  the  action  of  the  diaphragm  and   abdominal  muscles  in 
defecation,    and  to  contract  the  too  capacious  vagina.     For  this 
purpose    the    operation    last    recommended    for  vaginal  cystocele 
should  be  employed,  omitting  the  anterior  denudation  and  sutures. 
By  this  operation  the  perineum  is  thickened  and  rendered  capable 
of  supporting  the  rectum,  and  the  cavity  of  the  vagina  is  likewise 
diminished  in  size. 

PROLAPSE  OF  THE  ENTIRE  CIRCUMFERENCE  OF  THE  VAGINA. 

249.  This  form  of  displacement  is  very  rare,  and  occurs  as  the 
result  of  great  laxity  of  the   lining  membrane  of  the  vagina.     In 
its  mechanism  it  resembles  prolapsus  ani  ;  the  mucous  membrane 
and  the  cellular  tissue  beneath  it  being  extremely  lax,  this  cellular 
tissue  gives  rise  to  a  morbid  thickening  of  the  mucous  membrane, 
which  so  increases  its  weight,  that  it  overcomes  the  resistance  at 
the   outlet,    and   prolapse   is   the    consequence.     Prolapse   of  the 
vagina  may  be  either  partial  or  complete  ;  in  partial  prolapse  the 
mucous    membrane    merely    forms    a    prominence   within   the   os 
externum  ;    while   in   complete   prolapse,    the   mucous   membrane 
forms  a  circular  tumor  of  variable  size,  which  projects  beyond  the 
vulva.       Several   cases   are   reported  where   the   tumor   projected 
from  three  to  five  inches  beyond  the  vulva. 

250.  Symptoms. — The  symptoms  of  this  affection  vary  accord- 
ing to  the  amount  of  displacement ;  thus  in  slight  cases,  where 
the  tumor  does  not  project  beyond  the  vulva,  the  symptoms  wrill 
be  slight ;    as  a  feeling  of  weight  and   uneasiness  in   the  lower 
portion  of  the  vagina,  a  dragging  sensation  in  the  lower  portion 


132  DISEASES     OF     WOMEN. 

of  the  abdomen,  etc.  In  the  more  severe  forms  of  the  disease 
these  symptoms  become  greatly  aggravated  ;  there  is  a  discharge 
of  puriform  mucus,  obstinate  constipation,  difficulty  and  pain  in- 
passing  the  urine,  etc.  The  action  of  the  urine  on  the  tumor, 
and  the  friction  produced  by  exercise,  gives  rise  to  excoriation, 
and  often  to  inflammation.  On  examination,  the  tumor  will  be 
found  to  have  a  circular  form,  arising  from  the  entire  circumfer- 
ence of  the  vagina,  and  having  an  aperture  in  its  center.  On 
passing  the  finger  up  external  to  the  tumor,  it  will  be  stopped  in 
the  cul-de-sac  formed  between  the  tumor  and  the  vagina  ;  but  by* 
introducing  the  finger  through  the  central  orifice,  it  will  pass  up 
to  the  os  uteri. 

251.  Diagnosis. — It  may  be  distinguished  from  any  displace- 
ment of  the  uterus,  by  the  character  of  the  central  opening,  and 
by  the  fact  that  the  finger  can  be  passed  up  through  this,  and  the 
os  uteri  felt  above. 

252.  Treatment. — As  this  affection  occurs  for  the  most  part,  in 
persons  of   a  feeble   and    broken  down  constitution,  such  means 
should  be  employed  as  will  restore  the  general   health.     Where 
the  prolapse  is  slight  and  of  recent  origin,  it  will  be  found  that 
this,  with  the  use  of  vaginal  injections  of  cold  water,  will  remove 
the  difficulty.     Where  the  tumor  is  larger,  it  will  be  necessary  to 
replace  it  and  keep  it  in  position  by  means  of  the  pessary,  before 
recommended;  here,  also,  the  vaginal  injections  recommended  in 
the  other  two   varieties   of  prolapse   should   be    used.     If  these 
measures  should  fail  in  giving  relief,  and  the  patient  be  passed  the 
age   of  child-bearing,  it  would   be  proper  to   resort  to   surgical 
measures  for  the  relief  of  the  difficulty.     The  operation  proposed 
by  Dr.  Dieffenbach  for  the  permanent  relief  of  the  prolapse,  con- 
sisted in  replacing  the  tumor,  and  then  excising,  by  means  of  the 
forceps  and  scissors,  all  the  loose  folds  of  the  inner  surface  of  the 
labia  pudendi.     This  operation,  which  is  easily  performed,  should 
be  so  conducted,  that  the  folds,  as  they  are  removed,  constitute  so 
many  radii  converging  to  the  center  of  the  vagina,  so  as  to  allow 
the  upper  end  of  each  one  to  terminate  about  one  inch  within  the 
orifice    of   the    canal.     The   final    treatment   consists    in   merely 
cleansing  the  parts  once  a  day.     As  the  cut  surfaces  cicatrize, 


TUMORS,     MORBID     GROWTHS,     KTC.  133 

they  will  contract  the  orifice  of  the  vagina,  and  thus  furnish  a 
sufficient  support  to  the  parts.  The  same  end  may  be  accom- 
plished l>v  denuding  a  siiHieient  portion  of  the  va»-ina  of  its 

1  »/  1  c 

mucous  membrane,  and  bringing  the  cut  edges  of  it  together  and 
retaining  them  with  sutures. 

When  the  prolapse  has  been  of  long  standing,  and  the  tumor 
lias  become  irreduceable,  it  may  give  rise  to  so  much  incon- 
venience that  the  patient  may  insist  on  its  removal.  This  has 
been  successfully  accomplished  in  some  cases,  yet  it  is  a  dangerous 
operation,  and  should  never  be  undertaken  unless  absolutely 
required.  In  deciding  on  this  extreme  measure,  the  operator 
should  satisfy  himself  positively  that  the  rectum,  bladder,  and 
uterus  are  not  involved  in  the  displacement. 

TUMORS,  MORBID  GROWTHS,  ETC. 

253.  According  to  Prof.  Rokitansky,  the  occurrence  of  tumors 
or  morbid  growths  in  the  vagina  is  very  unusual.     The  cysts  that 
are  met  with  in  this  region   are  developed  in  the  cellular  tissue 
external   to  the  vagina,  and,  anatomically  speaking,  bear  a  very 
subordinate  relation  to  the  latter. 

Fibroid  productions  almost  invariably  coexist  with  similar 
growths  in  the  uterus ;  they  may  be  developed  in  the  external 
•fibro-cellular  layer  of  the  vaginal  parieties,  arid  especially  at  their 
posterior  surface ;  they  then  project  with  a  larger  or  smaller 
.segment  in  the  shape  of  round  tumors  into  the  vaginal  cavity. 
In  other  instances  they  are  developed  in  the  cellular  tissue,  that  is 
interposed  between  the  vagina  and  rectum,  and  though  in  close 
relation  to  the  vagina  in  point  of  origin,  project  chiefly  into  the 
rectum,  and  more  or  less  obstruct  its  inferior  portion. 

Warty  tumors  are  sometimes  developed  from  the  vaginal  mucous 
membrane,  oftener,  perhaps,  as  the  result  of  syphilis  than  from 
any  other  cause.  The  character  and  size  of  these  excresences 
vary  greatly,  though  they  generally  resemble  the  warty  tumors  of 
the  vulva.  These  tumors  are  generally  found  in  the  external  or 
vulvar  portion  of  the  canal. 

254.  Diagnosis. — Encysted  tumor  of  the  vagina  may  be  distin- 
guished from  vaginal  enterocele,  by  its  more  circumscribed  form, 


134  DISEASES      OF      WOMEX. 

and  from  the  fact  that  coughing  produces  no  enlargement  in  it. 
From  other  diseases  of  these  parts,  by  its  circumscribed  form, 
its  consistence,  and  by  the  fact  that  its  exact  location  can  be 
discovered,  by  an  examination  by  the  rectum  or  by  a  sound 
introduced  into  the  bladder. 

Fibrous  tumors  of  the  vagina  are  of  verv  rare  occurrence,  and 

v 

their  diagnosis  may  be  effected  by  the  means  already  pointed  out 
all  that  is  necessary  is  to  trace  out  their  exact  size  and  location, 
and  the  fact  that  no  other  disease  of  the  genital  organs  exists. 

255.  Treatment. — The  treatment    of   encysted  tumors   of   the 
vagina  is  the  same  that  was  recommended  for  the  same  disease  of 
the  labium  :  make  an  incision  into  the  tumor,  evacuate  its  contents, 
and  use  injections  of  Sesqui-Carbonate  of  Potassa,  to  destroy  the 
morbid  function  of  the  cyst-wall. 

Fibrous  tumors,  when  they  exist  in  the  vagina  of  sufficient  size 
to  produce  an  obstruction,  will  have  to  be  removed  with  the  knife. 
The  same  precautions  should  be  used  in  affecting  this,  that  was 
mentioned  in  describing  the  operation  for  occluded  vagina,  to 
prevent  wounding  the  bladder  or  rectum,  or  opening  through  the 
sides  or  upper  portion  of  the  vagina  into  the  pelvic  cavity. 

Warty  tumors  may  be  removed  in  the  manner  before  described, 
— removing  them  with  the  ligature  or  knife,  and  destroying  their 
base  with  caustic. 

CANCER  OF  THE  VAGINA. 

256.  "  Carcinoma  of  the  vagina  is,  in  most  cases,  cancer  of  the 
uterus,  which    has  spread  to  the  vagina  ;  it  may  exist  when  the 
latter  is  in  a  very  undeveloped  state,  and  even  without  it,  in  the 
shape  of  primary  carcinoma  of  the  vagina.     It  belongs   to  the 
fibrous   or  medullary  variety,  and,  in  proportion  to  its  growth, 
induces  thickening  of  the  parieties,  tuberculated  condensation  of 
internal  surface,  and  corresponding  contraction  of  the  passage. 
The  vagina  becomes  adherent  to  the  neighboring  parts  in  conse- 
quence of  cancerous  degeneration  of  the  cellular  tissue,  surround- 
ing it   and   the   rectum,  and,   finally,   cancerous   ulceration   and 
excrescences  are  established.     The    greater   part   of  the    vagina 
generally  becomes  involved,  and  sometimes  the  lower  portion  of  it 
becomes  prolapsed.     In  time,  the  disease  extends  to  the  rectum, 


C  A  N  C  E  K      ( )  I'      T  i  I  i:      V  \  G  I  X  A  .  135 

the  urethra,  the  bladder,  and,  if  the  uterus  was  not  primarily 
involved  to  it,  by  the  pressure  ii  exerts,  it  causes  retention  of  the 
urine  and  dilatation  of  the  bladder,  and,  when  it  has  reached  the 
ulcerative  stage,  recto  and  vesieo-vaginal  fistula  frequently  exist." 
2f>7.  Cancer  of  the  vagina  is  generally  more  painful  than  the 
same  affection  of  the  uterus,  owing  to  the  greater  sensibility  of 
this  canal.  The  peculiar  darting,  twisting  paiu  of  this  affection 
will  be  felt  at  the  seat  of  the  disease, — coming  on  and  going  off 
suddenly ;  at  times  extending  to  the  perineum,  down  the  inside 
of  the  thighs,  and  sometimes  in  the  course  of  the  sciatic  nerve,  as 
far  down  as  the  knee.  The  pain  in  the  back  is  usually  more 
severe  than  in  any  benign  affection  of  the  uterine  organs.  Upon 
making  an  examination,  the  diseased  part  will  be  felt  rough  and 
uneven  to  the  touch,  and  the  mucous  membrane  wrinkled  and  of  a 
leaden  or  purplish  color;  or,  if  ulceration  has  commenced,  the 
diseased  mass  will  present  a  fissured  appearance,  more  or  less 
elevated  above  the  surrounding  tissues,  of  a  dark-red  or  purplish 
color,  from  which  is  discharged  a  thin  fetid  and  excoriating  fluid. 

258.  Diagnosis. — Cancer  of  the  vagina  may  be  distinguished 
from  any  other  disease,  first,  by  the  character   and   intensity  of 
the  pain, — benign  tumors  of  this  canal  being  rarely  painful ;  by 
the  shape,  consistence,  and  color  of  the  tumor,— no  other  tumor 
presenting  the  same  shape  ;  condensation  of  the  adjoining  tissues, 
or  the  peculiar  dark-red  or  leaden  color.     But  supposing  the  points 
above-named    are    not    sufficient    to    distinguish    scirrhus  of   the 
vagina  from  other  morbid  growths,  whenever  the  affection  presents 
these  symptoms,  its  removal  is  necessary,  even  if  it  be  not  cancer, 
— the  mere  matter  of  furnishing  a  name  to  a  disease  being  of 
little  importance. 

259.  Prognosis. — The  prognosis  of   cancer   depends  upon   its 
size,   the   amount  of   tissue    involved,    its    position,    affection    of 
neighboring    organs,    the    bladder    and    rectum,    and,   especially, 
whether  the  disease  is  a  primary  affection  of  the  vagina,  or  has 
extended  to  it  from  the  uterus,  or  whether  the  uterus  has  become 
secondarily  affected.      If   the  disease    is    primary,  circumscribed, 
involving  neither  the  rectum,  bladder,  nor  uterus,  our  prognosis' 
should  be  favorable.     If,  however,  it  involves  a  large  portion  oi 


136  DISEASES     OF    WOMEX. 

the  vagina,  extending  to  the  rectum,  bladder,  or  uterus,  or  arises, 
as  it  very  commonly  does,  from  a  primary  affection  of  the  uterus, 
the  prognosis  is  unfavorable  ;  especially  if  the  disease  has  become 
constitutional  by  the  absorption  of  cancerous  material,  producing 
enlargement  of  the  lymphatic  glands,  general  debility,  or  the  same 
affection  in  any  other  portion  of  the  system. 

260.  Treatment. — Cancer  of  the  vagina,  unless  situated  near 
the  vulvar  orifice  and  on  the  posterior  wall  of  the  vagina,  does 
not  admit  of  any  operation  for  its  removal  with  the  knife,  owing 
to  the  thinness  of  the  vaginal  walls,  and  the  danger  of  wounding 
other   parts    contiguous.     If,    however,    it    is    situated    near    the 
perineum,  where  sufficient  space  exists  for  performing  excision, 
this    may   be    resorted   to    preparatory    to    the    means    hereafter 
recommended. 

261.  As  the  entire  removal  of  the  cancerous  growth  is  neces- 
sary to  effect  a  permanent  cure,  the  exact  extent  of  the  disease 
should  be  ascertained.     Our  main  dependence  in  its  removal,  is  in 
the   application  of  such   caustics   to   the  diseased  mass,    as   will 
destroy  every  vestige  of  it,  and  keep  up  the  suppurative  process, 
until  the  entire  action  of  the  parts  is  changed.     For  this  reason 
the  potassa  fusa  and  chloride  of  zinc,  have  been  found  the  most 
successful  agents.     The  caustic   potassa  is   preferred   by   many, 
from   the  fact  that   its  action   upon   the   tissues   can   be   readily 
checked  whenever  desired,  by  the  use  of  the  vegetable  acids.     In 
making  use  of  the  caustic  potassa,  it  should  be   applied  to  the 
entire  surface  of  the  diseased  mass,  destroying  it  as  much  as  pos- 
sible at  each  application.     The  best  means  of  using  the  potassa, 
is  to  place  a  stick  of  it  in  a  common  caustic-holder ;  introduce  the 
cylindrical  glass   speculum,   so  that  the  cancer  will  be  brought 
fairly  against  the  extremity  of  it,  and   then  apply  the   caustic, 
rubbing  it   strongly  against    the    part,  until    as    much  of   it    is 
destroyed  as  possible.     As  soon  as  the  speculum  is  withdrawn, 
injections  of  vinegar  and  water  should  be  used  to  neutralize  the 
action  of  the  potassa,   and  prevent  it  from  injuring  the   sound 
tissues. 

262.  The   chloride   of  zinc   may  be  used  in  these  cases,  by 
taking  a  saturated    solution   of   it,   and  mixing  with   it   enough 


VES1CO-YAGIXAL     FISTULA.  137 

pulverized  ulmus  fulva  to  form  a  paste  ;  spread  this  on  a  piece 
of  soft  leather  the  si/e  of  the  morbid  mass,  and  apply  it  through  a 
bivalve  speculum.  This  should  be  allowed  to  remain  for  half  an 
hour  to  two  or  three  hours,  keeping  the  vagina  distended  with  the 
speculum.  When  the  plaster  is  withdrawn,  we  may  restrain  the 
action  of  the  chloride  of  zinc,  by  using  injections  of  a  solution  of 
carbonate  of  soda. 

263.  In  place  of  these,  the   painless  cure  with  Arsenic  is  many 
limes   employed.      The    form    usually   adopted   is — R   Hyd rated 
Sesqui-oxide   of  Iron,  q.  s.;  throw   it   on    a  filter  and   allow    the 
water  to  drain  off  until  it  has  the  consistence  of  an  ointment;  to 
this  Arson ious  Acid  may  be  added   in   the  proportion  of  grs.  xx. 
to  jij.  to  the  3J.     It   is   continuously  applied   until   the    diseased 
structure  is   destroyed.     When   the  cancer  is   incurable,  we  use 
Carbolic  Acid  and  Glycerine  of  such  strength  as  gives  the  greatest 
relief  from  pain. 

VESICO- VAGINAL  FISTULA. 

264.  By  this  AVC  understand    the   existence  of   an   unnatural 
opening  between  the  bladder  and  the  vagina,  through  which  there 
is  an  involuntary  passage  of  urine.     There  is  probably  no  disease 
to  which  females  are  liable,  that  is  more  intractable  and  distressing 
than  this ;  the  constant  escape  of  the  urine  obliges  the  patient  tc 
confine  herself  at  home,  or  to  use  such  appliances  as  will  prevent 
the  escape  of  the  urine.     The  passage  of  the  urine  through  the 
vagina,  produces  a  continuous  irritation  of  the  mucous  membrane 
and  of  the  vulva,  excoriation,  pruritus,  etc.     The  attendant  suffer- 
ing is  modified  by  the  position  and  size  of  the  opening ;  thus,  if  it 
be  but  small  and  toward    the  outer  extremity  of  the  vagina,  it 
will  be  but  mild  in  comparison  with  those  cases,  where  the  opening 
is  large,  and  situated  in  the  upper  part  of  the  vagina.     In  these 
last  cases,  the  urine  can  not  be  retained  for  a  moment ;  for  as  fast 
as  it  is  secreted,  it  passes   down  the  sides  of  the  bladder  and 
escapes.     This    continuous    escape    of    urine    produces    such    an 
offensive  urinous  odor,  that  the  patient  is  debarred  from  society 
and  becomes  an  object  of  disgust  to  her  friends  and  attendants. 

265.  Causes,—  -The  most  frequent  cause  of  vesico-vaginal  fistula, 


138  DISEASES      OF      AVOMEX. 

is  the  long  impaction  of  the  head  of  the  child  in  the  pelvis  during 
labor,  the  anterior  parieties  of  the  vagina  being  subjected  to  long 
continuous  pressure,  may  be  the  seat  of  inflammation,  which  may 
terminate  by  sloughing  or  iilceration,  and  perforation. 

2d.  By  the  careless  or  improper  use  of  instruments  to  effect 
delivery. 

3d.  The  long  continued  presence  of  a  pessary  in  the  vagina, 
inducing  inflammation,  ulceration  and  perforation. 

4th.  Retention  of  urine  during  labor,  or  the  presence  of  a  cal- 
culus in  the  bladder  at  the  same  time,  will  generally  involve  more 
or  less  pressure,  giving  rise  to  subsequent  inflammation  and  per- 
foration. Retention  of  the  urine,  if  it  be  excessive,  causing  the 
bladder  to  project  into  the  pelvis  so  as  to  be  pushed  before  the 
head  of  the  child,  will  most  probably  prevent  delivery,  and 
occasion  rupture  of  the  bladder. 

5th.  Yesico-vaginal  fistula  may  result  from  venereal  ulcerations, 
cancer  of  the  uterus,  or  vagina,  etc. 

266.  Diagnosis. — The    detection    of  vesico-vaginal  fistula,    in 
many  cases,  requires  considerable  care.     Whenever  this  sad  con- 
dition is  suspected,  a  careful  examination  of  the  vesico-vaginal 
wall  should  be  made,  by  passing  a  sound  into  the  bladder,  turning 
its  point  downward,   so  that  it  may  be  felt  by  the  finger  of  the 
other  hand  introduced  into  the  vagina,  and  thus  with  the  finger 
against  the  sound,  examine  the  entire  extent  of  the  base  of  the 
bladder.     If  there  be  an  opening,  the  finger  will  come  in  contact 
with  the  sound  at  some   point  or  other.     The  vagina  should  be 
carefully   examined  with   the  speculum,   in   order  to   detect  the 
character  and  position  of  the  opening ;  probably  the  best  instru- 
ment for  this  purpose  is  the  cylindrical  glass  speculum ;  introduce 
it  to  the  cervix  uteri ;  turn  its  beveled  side  upward,  and  as  it  is 
withdrawn,  the  entire  anterior  wall  of  the  vagina  will  be  brought 
fairly  into  view;  the  reflective  power  of  this  instrument,  enabling 
the  physician  to  detect  the  slightest  change  of  structure. 

267.  Dr.  Ashwell  strongly  urges  the  importance  of  immediate 
attention  to  the  difficulty.     He  says :  "  When  it  is  known,  that 
laceration  of  parts  has   occurred  during  parturition,  the  involun- 
tary and  immediate  escape  of  the  urine  can  scarcely  be  attributed 


VESICO-TAG1NAL     FISTULA.  139 

to  a  wrong  cause;  but  it  is  quite  possible  that  incontinence  of 
urine  of  some  weeks  continuance,  may  be  produced  by  contusion 
of  the  neck  of  the  bladder,  by  which  its  relative  power  may  have 
been  partially  paralyzed;  still,  after  instrumental  labor,  especially 
where  the  necessary  assistance  has  been  too  long  delayed,  I  am 
always  glad,  when  the  first  twelve  days  are  over,  as  then,  we  may 
feel  pretty  confident,  if  the  urine  passes  naturally,  that  the  bladder 
and  urethra  have  escaped  that  dangerous  pressure,  which  so  often 
results  in  gangrene,  slough  and  fistula. 

268.  It  need,   therefore,   scarcely  be  urged,   if  there  be   any 
suspicion  of  laceration,  that  the  fact  should  be  ascertained  as  soon 
as  possible.     The  circumstances  attendant  on  recent  parturition, 
are  all   comparatively  favorable   to   cicatrization.     The  vagina  is 
relaxed  and  capacious ;  and  owing  to  the  weight  and  size  of  the 
uterus  having  as  yet  prevented  the  return  of  the  parts  to  their 
usual  hight   in  the  pelvis,   any  wound    of  the  urethra  or  vagina 
will  be  far  more  easily  seen,  and  effectually  treated,  than  when  the 
edges  of  the  perforation  have  become  separated  and  completely 
cicatrized.     Often  have  I  had  to  regret,  in  my  hospital  cases,  the 
effects  of  a  neglect  so  long  protracted,  as  to  allow  not  only  com- 
plete cicatrization,  but  adhesion  also,  of  the  torn   edges,  to  the 
neighboring  parts.     In  several  of  these  instances,  the  urethra  had 
entirely  ceased  to   convey  away  any  urine  at  all,  and  the  vagina 
had  become  so  exceedingly  contracted,  as  at  once   to  show  the 
utter  uselessness  of  remedial  measures.     It  is  right  to  state,  not- 
withstanding the  unfavorable  aspect  presented  by  most  of  these 
cases,  that  far  more  has  been  occasionally  effected,  than  even  the 
most  sanguine  practitioner  could  have  hoped." 

269.  Treatment. — The  results  of  treatment  in  effecting  a  cure, 
will  depend  much  upon  the  situation,  size,  direction  and  duration 
of  the  fistulous  opening.     Whatever  mode  of  treatment  is  adopted 
for  the  relief  of  the   difficulty,   it   should  be   preceded  by    such 
measures  as  will  restore  the  general  health,  if  affected,  and  correct 
any  diseased  condition  of  the  genital  organs,  which  would  inter- 
fere with  the  success  of  the  attempts  that  may  be  made,  to  close 
the  fistulous  opening. 

270.  The  methods  that  have  been  employed  for  the  treatment 


140  DISEASES     OF     WOMEN. 

of  these  fistulas,  are:  1st.  The  palliative  method.  2d.  Desault's 
method,  or  the  use  of  the  tampon.  3d.  Cauterization,  either  with, 
or  without  approximation  of  the  edges  of  the  fistula.  4th.  Suture. 
5th.  The  use  of  special  instruments  for  the  approximation  of  the 
edges  of  the  fistula.  6th.  The  restitution  of  the  part  by  ana- 
plasty. 

271.  Palliative  Method. — This  is  employed  where  the  loss  of 
substance  is  so  great  as  to  preclude  the  possibility  of  a  permanent 
cure,  or  in  those  cases  where  some  necessarily  fatal  disease  exists 
either  in  the  uterus  or  its  appendages,  or  of  some  other  portion  of 
the  system. 

The  means  to  be  employed  in  these  unfortunate  cases,  consists 
in  a  strict  attention  to  cleanliness,  the  frequent  use  of  emollient 
injections  to  counteract  the  irritating  effects  of  the  urine  upon  the 
vaginal  walls,  and  the  use  of  some  means  to  prevent  the  constant 
escape  of  the  urine.  For  this  last  purpose,  many  contrivances 
have  been  used,  and  yet  very  few  of  them  have  proved  sufficient 
to  completely  relieve  this  inconvenience.  Probably,  the  best 
apparatus  for  this  purpose  would  be  a  gum-elastic  bottle  of  suffi- 
cient size  to  hold  the  secretion  of  six  or  twelve  hours ;  the  neck 
of  this  should  be  of  sufficient  size  to  fit  close  to  the  walls  of  the 
vagina,  and  of  sufficient  thickness  to  cause  a  continuous  pressure 
against  them,  and  thus  prevent  the  passage  of  the  urine  down  the 
sides  of  the  bottle.  This  apparatus  can  be  supported  by  a 
perineal  bandage ;  it  should  be  frequently  emptied,  and  carefully 
cleaned  each  time,  especially  the  vaginal  portion,  to  prevent  irri- 
tation and  excoriation  of  the  parts.  The  use  of  fine  sponges 
introduced  into  the  vagina,  or  applied  to  the  vulva  and  frequently 
renewed,  will  also  be  found  a  useful  means  of  relieving  this 
inconvenience. 

272.  Default's  Method. — This   consists  in  keeping  a  catheter 
permanently  in  the  urethra,  and  plugging  the  vagina  with  a  cylin- 
der of  lint,  linen  or  gum-elastic,  and  thus  divert  the  discharge 
from  its  unnatural  channel,  and  allow  this  to  close  up.     Several 
authors    report    cases    of  cure    by    these    means.      This    method 
requires  from  six  to  ten  months  to  effect  a  cure,  even  when  it  is 
successful,  and  in  many  cases  the  retention  of  the  catheter  for  this 


V  EM  CO- VAC  IX  AL     FIST  I"  I.  A.  141 

lengtli  of  time,  is  entirely  impracticable,  owing  to  the  irritability 
of  the  bladder  and  the  urethra. 

The  apparatus  made  use  of,  by  this  surgeon,  to  retain  the 
catheter  in  the  urethra,  consisted  of  a  spring  truss,  which  had 
attached  to  it  a  steel  plate,  which  rested  on  the  mons  veneris  ;  to 
this  plate  was  attached  a  small  curved  rod,  which  passed  downward 
over  the  vulva,  and  terminated  opposite  the  meatus  urinarius  in  a 
perforation  to  receive  the  catheter  ;  which,  after  being  introduced, 
was  attached  to  it.  The  edges  of  the  fistula  were  brought  in 
apposition  as  much  as  possible,  by  the  vaginal  tampon.  This 
method,  with  the  following  modifications,  might  be  used  with 
success  in  some  cases  of  transverse  fistula.  1st.  The  edges  of  the 

o 

fistula  should  be  freshened,  either  with  the  knife  or  by  cauterization, 
in  order  to  promote  speedy  adhesion.  2d.  The  vaginal  tampon 
should  not  be  large  enough  to  produce  much  distention  of  the 
vaginal  walls :  an  India  rubber  bag,  distended  with  air,  would 
probably  answer  the  purpose  better  than  any  thing  else,  as  it 
adapts  itself  to  the  shape  of  the  vagina  ;  before  this  is  introduced, 
the  edges  of  the  fistula  should  be  brought  together  by  elevating 
the  perineum,  and  pressing  the  uterus  and  bladder  downward. 
3d.  A  compress  should  be  applied  over  the  hypogastrium,  to  keep 
the  pelvic  contents  depressed,  and  a  perineal  supporter  worn  to 
elevate  the  perineum,  and  in  this  manner  to  keep  the  edges  of  the 
fistula  approximated.  4th.  Perfect  quiet,  in  a  reclining  position, 
should  be  enjoined,  until  the  fistula  has  closed. 

273.  Cauterization. — This  method  has  proved  successful  in  the 
hands  of  many  surgeons,  yet  like  all  other  measures  proposed  for 
the  relief  of  this  difficulty,  the  failures  have  been  much  more 
numerous  than  the  cures.  The  beneficial  effects  of  cauterization 
in  effecting  the  closure  of  these  fistulas,  may  be  ascribed,  1st,  to 
the  freshening  of  the  edges  of  the  fistula,  and  thus  placing  them 
in  a  condition  favorable  to  their  cohesion  ;  2d,  to  the  deposition  of 
coagulable  lymph,  the  effect  of  the  inflammation  excited,  which 
causes  a  thickening  of  the  edges,  and  by  the  contraction  of  the 
new  deposit,  which  resembles  a  cicatrix,  they  are  approximated, 
either  entirely  closing  the  opening,  or  considerably  lessening  it. 
Cauterization,  to  be  successful,  should  be  restricted  to  those  casc\s 


142  DISEASES     OF     WOMEX. 

in  which  the  fistulous   opening   is   small,  as   in  cases   where  the 
perforation  is  large  it  will  surely  fail. 

274.  According  to  Yelpeau,  this  is  one  of  the  best  means  which 
have  been  tried  up  to  the  present  time.     (Ope.  Sur.,  1847.     Vol. 

II.,  p.  855.)  Used  to  the  extent  of  irritating  and  of  inflaming 
the  tissues  to  a  sufficiently  intense  degree,  without  effecting  their 
mortification,  it  produces  an  engorgement  and  intumescence  which 
closes  up  or  contracts,  at  least  for  the  time  being,  the  opening 
which  we  are  desirous  to  heal  up.  After  the  subsidence  of  the 
engorgement,  the  exhalation  and  suppuration  are  accompanied 
with  a  manifest  tendency  to  colirctation.  This,  therefore,  is  a 
method  which  deserves  all  the  attention  of  the  practitioner,  and 
one  which  appears  to  be  especially  calculated  to  succeed,  where 
the  perforation  has  but  little  extent.  The  cauterization  is  effected 
by  means  of  the  actual  Cautery,  or  Nitrate  of  Silver.  The  incan- 
descent Iron  has  the  advantage  of  acting  with  more  rapidity  and 
with  greater  energy.  Unfortunately,  it  exposes  to  the  risk  of 
forming  an  eschar,  and  of  destroying  the  tissues  which  we  only 
wish  to  inflame.  The  Nitrate  of  Silver  is  generally  preferable, 
and  the  actual  Cautery  ought  not  to  be  substituted  in  its  place, 
except  in  some  particular  cases ;  as,  for  example,  when  the 
borders  of  the  fistula  are  callous,  or  can  not  be  inflamed  without 
too  much  difficulty." 

275.  In   applying   the  Nitrate  of  Silver  to   the   edges   of  the 
fistula,  a  fenestrated  speculum   should  be   used,  which  will  leave 
the  upper  surface  of  the  vaginal  canal  exposed;  then,  by  fasten- 
ing a   piece  of  the  stick  Nitrate  of  Silver  to  the  extremity  of  a 
pair  of  dressing  forceps,  by  means  of  a  thread,   so  that  it  will 
form  a  projection  at  right  angles,  to  the  border  of  the  instrument ; 
the  entire  circumference  of  the  opening  may  be  easily  cauterized. 
The  caustic  should  be  lightly  applied  as  the  object  is  not  to  pro- 
duce a  slough,  but  to  excite  a  sufficient  degree  of  inflammation  to 
produce  effusion,  and  subsequent  contraction.     Much  care  should 
be  used  to  bring  the  caustic  in  contact  with  the  entire  thickness 
of  the  vesico- vaginal  wall,   for  if  but  the    vaginal  portion    was 
touched,  leaving  the  vesical  edges  uncauterized,  there  would  be 
no  hope  of  a  successful  result.     If  much  pain  should  follow  the 


VES1CO- VAGINAL     FISTULA.  143 

application  of  the  caustic,  it  would  be  well  enough  to  use  one  or 
inore  vaginal  injections  of  warm  water,  or  place  the  patient  in  a 
warm  hip-bath.  A  catheter  (should  be  allowed  to  remain  in  the 
urethra,  if  it  docs  not  produce  irritation.  The  patient  should  be 
placed  in  bed,  and  kept  perfectly  quiet,  to  prevent  the  breaking 
up  of  any  adhesions  that  may  form.  This  operation  may  be 
repeated  as  often  as  may  seem  necessary,  providing  the  patient  is 
benefitted  by  it ;  allowing  the  irritation  to  subside  each  time  before 
again  resorting  to  the  caustic. 

276.  Suture. — This  method   has  long  been   known,  and  prac- 
ticed by  the  profession,  with  variable  results.     In  many  cases,  it 
has  proved  entirely  successful ;  in  others,  and  probably  the  major- 
ity of  those  operated  upon,  it  has  failed.     In  order  to  succeed  in 
closing  the  fistula  by  the  suture,  it   is   necessary,  1st.   That  the 
edges  of  the  fistula  should  be  entirely  freshened,  so  that  they  may 
unite  by  first  intention.     2d.   That  the  sutures  should  perfectly 
approximate  the  edges.      od.    That  they  should  retain  them  in 
apposition,  until  the  union  is  complete. 

277.  Probably  one  of  the  most  difficult  parts  of  this  operation 
is  freshening  the  edges  of  the  fistula,  especially  where  it  is  situated 
in  the  upper  portion  of  the  vagina.     To  accomplish  this,  we  might 
use  the  scissors — straight  or  curved — and  a  small  scalpel ;  holding 
the  edges  with  a  pair  of  forceps  having  a  movable  joint  about  an 
inch  from  their  extremity,  so  arranged  that  they  can  act  in  every 
direction,  and  be  applied  to  any  portion  of  the  opening.     If  the 
fistula  is  longitudinal,  these  instruments  will  be  entirely  sufficient. 
The  posterior  angle  of  the  fistula  should  be  divided,  for  one  or 
two   lines,  with    the    scissors,  and    the    anterior    angle   the    same 
distance  with  the  scalpel ;  then,  by  holding  the  edges  with  the 
forceps,  they  may  be  trimmed  off  for  about  a  line,  either  with 
the  scissors  or  a  scalpel.     In  the  transverse  fissure  these  instru- 
ments may  be  advantageously  replaced  with  the  cutting  forceps  of 
Colombat.     These  forceps  are  made  like  those    above-described, 
with  their  extremities  movable ;    one  of  them  terminating  by  a, 
small  leaden  plate,  intended  to  sustain  the  edges  of  the  fistula, 
while    the   other  has  upon  it  a  sharp,  cutting  edge.     With  this 
instrument  the  edges  of  any  fistula  can  be  accurately  trimmed. 


DISEASES     OF     WOMEX, 


278.  The  suture  best  adapted  to  approximate  the  edges  of  the 
fistula,  and  to  retain  them  in  apposition,  is  that  used  by  Dr.  Sims, 
which  he  calls  the  clamp-suture.  It  is  formed  of  annealed  silver 
wire,  about  the  size  of  horse-hair,  which,  being  passed  through 
he  edges  of  the  fistula,  are  fastened  to  cross-bars,  like  the  quilled 
suture.  These  cross-bars  are  also  silver,  or  lead  highly  polished, 
and  pierced  with  as  many  holes  as  there  are  ligatures  to  be 
applied.  These  ligatures,  after  being  introduced,  are  passed 
through  the  perforation  of  the  cross-bars,  drawn  sufficiently 
tight  to  approximate  the  edges  of  the  fistula,  and  then  fastened 
by  slipping  a  perforated  shot  over  the  wire  and  compressing  it  at 
the  cross-bar.  Dr.  Sims  states  that  this  suture,  properly  applied, 
never  ulcerates  out,  having  always  to  be  removed.  It  may  be 
allowed  to  remain  as  long  as  ten  days  after  scarifying  the  edge  of 
the  fistula. 


Fia.  14. — OPERATION  FOR  VESICO -VAGINAL  FISTULA.     SHOWING  THE  APPROXIMA- 
TION OF  THE  EDGES  OF  A  TRANSVERSE  FISTULA  BY  MEANS  OF  THE  CLAMP-SUTURE. 

279.  The  position  for  operating,  recommended  by  Dr.  Sims,  was 
"  to  place  the  patient  on  her  elbows  and  knees  on  a  suitable  table 
the  knees  separated  some  six  or  eight  inches,  the  thighs  at  about 
right-angles  with  the  table,  and  the  clothing  all  thoroughly  loosened, 


VESICO-VAGINAL     FISTULA.  145 

so  that  there  shall  be  no  compression  of  the  abdominal  parieties. 
An  assistant  on  each  side  lays  a  hand  in  the  fold,  between  the 
glutei  muscles  and  the  thigh,  the  ends  of  the  fingers  extending  quite 
to  the  labia  majora ;  then,  by  simultaneously  pulling  the  nates 
upward  and  outward,  the  os  externum  opens,  the  pelvic  and 
abdominal  viscera,  all  gravitate  toward  the  epigastric  region,  and 
stretching  this  canal  out  to  its  utmost  limits,  affording  an  easy 
view  of  the  os  tincee,  fistula,  etc.  To  facilitate  the  exhibition  of 
the  parts,  the  assistant  on  the  right  side  of  the  patient  introduces 
the  lever  speculum,  and  then,  by  lifting  the  perineum,  stretching 
the  sphincter,  and  raising  up  the  recto-vaginal  septum,  it  is  as 
easy  to  view  the  whole  vaginal  canal  as  it  is  to  examine  the  fauces 
by  turning  a  mouth  widely  open  to  a  strong  light." 

The  method  proposed  by  Dr.  Hayward  may  be  advantageously 
used  when  the  fistula  is  near  the  neck  of  the  bladder,  or  in  the 
urethra.  The  patient  being  placed  under  the  influence  of  chloro- 
form, the  bladder  is  depressed  by  introducing  a  large  sized  bougie 
into  the  urethra,  to  the  very  fundus  of  the  bladder,  then,  by 
carrying  the  other  end  up  to  the  pelvis,  the  bladder  is  depressed, 
and  the  fistula  is  readily  brought  in  sight.  In  this  position,  the 
edges  may  be  readily  pared,  and  the  sutures  introduced  in  the 
manner  already  directed. 

280.  Whatever  position  the  patient  is  placed  in,  as  soon  as  the 
parts  are  fairly  exposed,  the  operator  should  carefully  and  nicely 
trim  the  edges  of  the  fistula  in  the  manner  heretofore  described, 
leaving  no  part  of  it  unfreshened.  A  ligature  of  silk  should  then 
be  carried,  by  means  of  a  spear-pointed  suture  needle,  curved,  to 
correspond  to  the  direction  of  the  fistula,  through  the  two  lips  of 
the  opening.  The  amount  of  tissue  inclosed  by  the  suture,  should 
be  at  least  half  an  inch  on  each  side  of  the  freshened  surfaces. 
Thus,  in  a  transverse  fistula,  the  straight  needle  should  be  intro- 
duced half  an  inch  anterior  to  its  edge,  pushed  deeply  into  the 
vaginal  septum,  carrying  it  upward  into  the  cellular  tissue,  uniting 
the  vagina  and  bladder,  and  bringing  it  out  just  before  the  mucus 
lining  of  the  bladder ;  then  introducing  it  into  the  corresponding 
portion  of  the  upper  lip  of  the  fistula,  it  should  traverse  it  in  the 
same  manner,  and  be  brought  out  the  same  distance  above. 
10 


146  DISEASES    OF    WOMEX. 

Having  introduced  the  requisite  number  of  ligatures  in  this 
manner,  brin^incr  their  ends  out  at  the  vulva,  each  is  made  to  act 

O        O  ' 

as  a  guide  to  the  silver  wire,  which  is  to  take  its  place.  These 
wires,  twelve  or  eighteen  inches  in  length,  being  attached  to  the 
extremities  of  the  silk  threads,  are  drawn  by  them,  until  the  wires 
occupy  their  place.  One  end  of  the  wires  are  then  passed  through 
the  perforation  in  one  of  the  cross-bars,  and  clamped,  by  pressing 
a  perforated  shot  down  upon  them.  After  this  is  placed  in  its 
proper  position,  the  other  cross-bar  should  be  introduced  in  the 
same  manner,  tightening  the  wires  until  the  edges  are  approxi- 
mated, and  then  clamping  them  with  a  perforated  shot ;  after  the 
cross-bars  are  secured,  the  ends  of  the  wire  should  be  clipped  off 
close  to  the  shot. 

281.  As  soon  as  the  operation  is  concluded,  the  patient  should 
be  placed  in  bed,  on  her  side,  the  hips  elevated,  and  the  thighs 
flexed  upon  the   abdomen.     A  self-retaining  catheter   should  be 
introduced,  and   allowed  to  remain,  excepting   when  it  becomes 
necessary  to  clear  the  mucus  and  earthy  deposit  from  it. 

282.  Mr.  Baker  Brown  strongly  urges  the  importance  of  keep- 
ing the  bowels  constipated,  by  means  of  opium,  to  secure  success 
in  this  operation.     His  reasons  for  adopting  this,  instead  of  the 
common  practice,   of  keeping  the  bowels  loose,  are  :  it  prevents 
that  disturbance   of   the    coalescing    parts,   which   is    so    apt  to 
follow  a  motion  of  the  bowels ;  and  that  it  proves  actually  benefi- 
cial, by  allaying   irritation,  controlling   inflammation,   and   thus, 
generally  favoring  the   healing    process.      This    plan   has    been 
adopted  by  several  of  the  most  successful  operators,  and  so  far, 
has  been  followed  by  no  ill  effects.     The  patient  should  be  kept 
perfectly  quiet  for  the  first  six  or  eight  days,  and  if  any  examina- 
tion is  made  within  this  time,  it  should  be  done  with  a  very  small 
bivalve-speculum,  being  very  careful  not  to   interfere    with  the 
suture.     If  no  urine  has  passed  through  the  fistula  by  this  time, 
the  nature  of  the  adhesions  may  be  ascertained,  and  if  sufficient, 
the  sutures  should  be  removed ;  where  there  is  any  doubt,  how- 
ever, on  this  point,  they  may  be  left  until  the  fifteenth  or  sixteenth 
day,  providing  they  do  not  produce  too  great  irritation,  or  ulcera- 
tion  has  not  commenced  around  the  ligatures. 


VKSICO-VAG  I  XAL      FISTULA.  117 

283.  Special  Instruments  for  the.  Approximation  of  the  Edyes 
of  the  Fixtula. — Many  contrivances  have  been  used,  to  approxi- 
mate the  edges  of  a  fistula,  yet  none  up  to  this  time,  have  proved 
as  successful  as  the  suture.     The   instruments  invented,  and  used 
by  M.  Lallemand  and   M.  Laquier,  were  intended  to  approximate 
and    keep   in    apposition  the  edges  of   the  fistula,  by  means  of 
small  hooks,  which  pass  into  the  vesico-vaginal  septum.     The  first 
author  used  a  silver  catheter,  in  which  was  concealed  curved  hooks 
connected  to  a  screw,  which  projected  from  the  external  extremity 
of  the  instrument.     By  drawing  upon  this  screw,  the  curved  hooks 
"were  caused  to  project  through  the  eyes  of  the  instrument  at  will. 
This  catheter  was  introduced  through  the  urethra  to  the  bladder, 
and  the  hooks  made  to  perforate  the  posterior  lip  of  the  fistula, 
about   half  an   inch   from    its   edge ;   then   by   drawing   upon   the 
catheter,   and  pressing  the  urethra  backward,  by  a  silver  plate 
passed  upon  the  instrument,  and  guarded  by  charpie,  the  edges 
•were  approximated,  the  apparatus  being  retained  in  this  position 
until   the  fistula  was   closed.     The  instrument  of  M.  Laquier  was 
introduced  through  the  vagina,  and  consisted  of  a  pair  of  hooked 
forceps.      The  principle   involved  in   both  instruments,    was    the 
same,  and  neither  of  them  has  been  successful,  from  the  fact,  that 
the  hooks  either  tear  or  ulcerate  out  before  union  is  effected. 

284.  Anaplasty. — The  cure  of  vesico-vaginal  fistula  by  trans- 
plantation, was  first  attempted  by  M.  Jobert,  but  the  operative 
process  was  copied  from  that  made  use  of  by  Velpeau,  in  treating 
bronchial  fistula.     The  following  description  of  Jobert's  operation 
I  have  taken  from  Velpeau' s  Surgery.     "The  fistula  is  abraded 
Vy  means  of  caustic   or  a  cutting   instrument ;    a  flap  of  much 
greater  length  than  width,  and  also  of  greater  or  less  length  or 
breadth,  according  as  the  fistula  itself  is  of  greater  or  less  size, 
or  more  or  less  deeply  situated,  is  then  cut  upon  one  of  the  sides 
of  the  vulva,  so  that  its  point  shall  be  turned  toward  the  sub- 
ischiatic  groove,  and  that  its  root   may  be   continuous  with  the 
vulvar  opening  of  the  vagina.     Dissected  and  separated   from  its 
apex  toward  its  base,  this  flap  should  be  sufficiently  long  to  be 
drawn  without  difficulty  through  the  fistula,  into  the  bladder  or 
urethra.     Having  folded  it  upon  its  cutaneous  face,  we  pierce  the 


148  DISEASES      OF      TTOMEN. 

fold  with  a  double  thread ;  this  thread,  which  is  to  serve  as  its- 
conductor,  being  attached  to  the  head  of  Belloeque's  sound  previ- 
ously introduced  into  the  urethra  through  the  vagina,  easily  draws 
the  tegumentary  plug  toward  the  fistula,  and  prevents  it  after- 
ward from  falling  back  into  the  vagina.  As  the  presence  of  the- 
thread  in  the  urethra  might  cause  ulceration,  it  would  be  advan- 
tageous to  pass  it  through  a  female  catheter,  which  would  serve 
as  a  support,  at  the  same  time  that  it  would  give  egress  to  the 
urine.  It  is  evident,  also,  that  the  flap  may  be  taken  almost 
indifferently  from  the  tissue  of  one  of  the  labia  majora,  or  from 
the  inner  surface  of  the  thigh  or  near  the  breech.  The  important 
point  is,  that  it  may  have  a  certain  degree  of  thickness,  especially 
on  the  side  of  its  pedicle ;  otherwise  with  the  length  we  are 
obliged  to  give  it,  it  would  be  next  to  impossible  to  prevent  its 
mortification.  Perhaps,  it  would  be  well  also,  after  having 
doubled  it,  to  keep  it  thus  folded  at  its  point  by  means  of  one 
stitch  of  suture,  and  to  let  it  contract  itself  and  become  vascular- 
ized,  before  introducing  it  into  the  vagina.  It  would  also  be 
advantageous,  I  think,  to  draw  it  by  its  larger  extremity,  and  to 
use  some  force  to  make  it  enter,  in  order, that  its  largest  portion 
being  in  the  bladder,  might  in  some  measure  be  retained  under- 
neath, by  the  fistula  itself,  which  would  then  perform  the  office  of 
a  constricting  ring.  What  is  also  necessary  is,  that  the  flap 
should  be  placed  in  contact  with  the  fistula,  by  its  cellular,  and 
not  by  its  cutaneous  surface,  and  that  the  edge  of  the  fistula 
should  be  in  a  state  of  abrasion.  In  this  manner  no  stitches  of 
suture  are  necessary,  and  the  parts  may  remain  in  their  places  of 
themselves.  We  should  not  think  of  dividing  the  pedicle  of  the 
flap,  till  at  the  end  of  some  weeks,  and  after  having  positively 
ascertained  that  a  solid  agglutination  has  taken  place  between  the 
new  substance  and  the'  periphery  of  the  fistulous  opening.  This 
section,  also,  should  be  made  toward  the  middle  of  the  length  of 
the  flap,  in  order  that  in  retracting  by  its  near  extremity,  it  may 
ultimately  form  a  sort  of  button  with  two  heads ;  one  in  the 
vagina,  the  other  in  the  bladder." 

285.    This   method   has   proved   successful,   in   the   hands   of 
M.  Jobert,  in  several  instances,  and  the  fact  that  it  is  one  of  the 


RECTO-VAGINAL     FISTULA.  149 

easiest  operations  to  be  performed,  should  recommend  it  to  the 
attention  of  the  profession.  In  order  that  it  may  be  successful, 
the  same  care  will  have  to  be  used  in  the  after  treatment,  as 
recommended  in  operating  with  the  suture.  If  the  union  is  not 
complete  around  the  entire  circumference  of  the  fistula,  after  a 
sufficient  time,  the  edges  may  be  touched  with  the  Nitrate  of 
Silver,  to  favor  adhesion. 

RECTO-VAGINAL  FISTULA. 

286.  By   this  we    understand    the   existence   of  an   unnatural 
opening  between  the  vagina  and  the  rectum,  which  gives  passage 
to  involuntary  discharges  of  flatus  and  faeces.     These  fistulas,  which 
are  generally  longitudinal  in  direction,  may  arise  from  either  of 
the  following  causes.     First.  From    some    cause   connected  with 
labor,  as  from  the  prolonged  pressure  of  the  child's  head,  giving 
rise  to  inflammation  and  sloughing,  from  the  careless  or  awkward 
use  of  instruments,  or  from  laceration  during  delivery.     Second. 
From  a  recto-vaginal   abscess  or   from   a  pelvic  abscess,  which 
opens  in  two  directions,   perforating  the  vagina  and  the  bow%el. 
Third.  From  stricture  or  other  disease  of  the  rectum.     Fourth. 
From  cancer  or  corroding  ulcer,  either  of  the  rectum  or  vagina; 
•or  from  syphilitic  ulceration. 

287.  This  disease,  though  not  in  general  as  distressing  to  the 
patient  as  the  one  last  described,  is  a  source  of  constant  annoyance. 
If  the  opening  be  large,  admitting  the  involuntary  escape  of  fecal 
matters,  the  condition  of  the  patient  is  most  pitiable ;  the  passage 
of  the  faeces  over  the  edges  of  the  fistula  and  through  the  vagina 
keep  up  a  continuous  irritation  which  sometimes  runs  into  a  severe 
erythematous  inflammation.     Even  if  the  existence  of  the  local 
injury  does  not  effect  the  general  health  of  the  patient ;  the  distress 
of  mind    occasioned   by  her   unpleasant    condition,   is    generally 
sufficient  to  do  so  ;  she  is  cut  off  from  society,  and  in  the  solitude 
of  her  own  sufferings,  her  spirits  and  health  are  apt  to  fail. 

288.  The  seat  and  character  of  this  fistula  may  be  ascertained 
by  an  examination  by  the  rectum  and  the  vagina.     Ascertain  first 
the  position   of  the  vaginal  opening,  by  means  of  the  speculum, 
then  by  introducing  the  finger  into  the  rectum  and  passing  a  probe 


150  DISEASES     OF    AVOMEX. 

from  the  vagina  through  the  fistula,  until  it  can  be  felt  in  the 
rectum ;  the  character  of  the  opening  can  be  determined.  If, 
from  any  cause,  the  probe  can  not  be  passed  through  the  fistula, 
injections  passed  through  it  will  enable  the  operator  to  determine 
its  course. 

289.  Treatment. — The  tendency  to  spontaneous  cure  is  con- 
siderable in  recto-vaginal  fistula,  when  it  arises  from  accidental 
causes.  As  the  neighboring  parts  contract,  concentrically  toward 
the  opening,  so  does  it  diminish,  narrow,  and  sometimes  close 
entirely  up.  The  development  of  granulations  from  the  edges  of 
the  fistula,  likewise  contributes  to  fill  up  the  space  and  especially 
to  form  the  cicatrix.  Thus  fistulous  openings,  of  which  the  size 
is  so  great  as  to  do  away  with  all  hope  of  occlusion,  are,  not- 
withstanding, more  or  less  closed  up  in  the  course  of  time. 

The  treatment  in  this  variety  of  fistula  will  be  the  more  suc- 
cessful the  sooner  it  is  resorted  to  after  the  opening  has  formedr 
and  it  is  at  this  time  that  the  attention  of  the  physician  should  be 
especially  drawn  to  them.  As  this  primary  treatment  will  depend 
much  upon  the  cause,  we  will  consider  it  in  this  relation. 

If  it  arises  from  sloughing  after  prolonged  pressure  of  the 
child's  head,  the  natural  tendency  of  the  parts  to  close  Avill  not 
be  so  strong,  as  where  it  arises  from  the  other  causes  named. 
The  treatment  in  this  case  consists  in  a  careful  attention  to  clean- 
liness, quiet,  and  the  use  of  stimulating  applications  to  the  edges 
of  the  opening ;  as  a  solution  of  Sulphate  of  Zinc  or  Sesqui- 
Carbonate  of  Potassa  of  sufficient  strength.  If  the  fistula  is  of 
long  standing  we  will  have  to  resort  to  the  means  recommended 
for  vesico-vaginal  fistula,  cauterization,  paring  the  edges,  and  use 
of  the  suture,  or  anaplasty.  The  application  of  these  methods  is 
so  similar  to  that  described  for  the  other  variety  of  fistula,  that 
a  repetition  would  be  useless.  If  the  fistula  arises  from  laceration 
of  the  vagina,  either  as  the  result  of  an  improper  use  of  instru- 
ments or  not,  the  patient  should  be  kept  quiet  in  bed,  with  the 
thighs  flexed  upon  the  abdomen  and  tied  together,  and  the  peri- 
neum supported  by  a  well-adjusted  perineal  bandage.  As  the 
intention  is  to  favor  the  union  of  the  parts  by  first  intention,  the 
bowels  should  be  kept  constipated  to  prevent  any  strain  upon  the 


R  K  c  T o -  v  A  G  i  x  A  i,    v  i  s  T  u  LA.  151 

parts,  and  the  urine  drawn  off'  with  the  catheter  as  often  as  it  may 
be  necessary. 

290.  When  the  fistula  arises  from  a  recto-vaginal  abscess,  it 
will  generally  yield  to  the  application  of  caustics.     If  this  does 
not  succeed,  or  if  the  fistula  is  of  very  long  standing,  we  will  have 
to  resort  to  the  means  described  under  the  head  of  vesico-vagina 
fistula.      Those  fistulas  that  arise  from  pelvic  abscesses  are  some- 
times very  tortuous,  and   extremely  hard  to  manage.     No  definite 
rules  can   be  laid   down   for  their  treatment.     For  a   case  of  this 
kind  successfully  treated  by  Dr.  Barton,  on  a  new  plan,  see  Amer- 
ican Journal  of  Medical  Sciences,  for  June,  1840.     If  the  fistula 
arises  from  stricture  or  other  disease  of  the  rectum,  the  removal 
of  this  will  often  be  found  sufficient  to  close  the  opening ;  at  any 
rate  this  should  be  first  accomplished,  and  if  the  fistula  does  not- 
then  close,  it  should  be  treated  by  some  of  the  methods  already 
mentioned.     If  it  is  caused  by  cancer  of  the  rectum  or  vagina, 
palliative  treatment  can   alone  be  adopted,  allaying  the  irritation 
with  opium  or    other    narcotics,   and    cleansing    the    parts    with 
frequent  injections  of  warm  water,  etc. 

291.  As    the    principles    of  treatment    are    the    same   in   thi 
disease  as   in   vesico-vaginal    fistula,    the  same  attention  will  be 
required  in  the  after  treatment.     If  the   suture  is   used,  or  the 
fistula  closed  up  by  anaplasty,  it  is  highly  important  that  consti- 
pation of  the  bowels  should  be  kept  up,  as  a  much  greater  degree 
of  success  has  attended  this  plan,  than  that  of  keeping  them  loose 
with  fluid  discharges.     The  success  attending  operations  for  this 
lesion  is  much  greater  than  that  for  vesico-vaginal  fistula,  owing 
to  the  fact  that  the  recto-vaginal  septum  has  greater  thickness, 
and  is  not  so  movable,  and  that  all  discharges  may  be  prevented 
by  the  use  of  opium. 

292.  The  following  interesting  case  of  recto- vaginal  and  double 
perineal  fistula,  the  result  of  Syphilis,  successfully  treated  by  my 
colleague,  Prof.  Z.  Freeman,  presents  many  points  of  interest,  and 
illustrates  the  difficulties  to  be  met  with  in  the  treatment  of  these 
diseases,  as  well  as  the  success  that  may  be  expected  to  follow 
the  persevering  application  of  the  principles  heretofore  mentioned 
This  case  was  reported  in  the  Eclectic  Medical  Journal  for  April 


152  DISEASES     OF    WOMEN. 

1855.  "Miss  E.,  aet.  18,  of  sanguine-bilious  temperament  con- 
tracted syphilis,  two  years  since.  There  were  two  small  chancres 
on  the  labia  majora,  one  at  the  junction  of  the  right  nymphas 
with  the  vagina,  and  one,  larger  and  deeper,  at  the  fourchette. 
The  former  was  soon  healed  by  the  application  of  Arg.  Xit., 
followed  by  the  black  wash  ;  but  the  latter  did  not  heal — the 
vagina]  secretion  keeping  it  constantly  irritated.  During  its 
early  period  it  was  very  troublesome,  by  its  constant  irritation  ; 
but,  the  chronic  stage  coming  on,  it  pained  her  but  little.  The 
ulceration  continued  slowly,  until  it  burrowed  a  deep  cavity  in 
the  perineum,  between  the  fourchette  and  rectum.  The  pus  and 
vaginal  secretion  accumulating  induced  fistulse  of  the  perineum, 
one  opening  through  the  middle  of  the  perineum,  on  the  raphe, 
another  opening  at  the  junction  of  the  right  thigh  with  the 
perineum,  and  a  third  on  the  left  side,  opposite  the  second.  The 
two  latter  also  communicated  with  each  other  across  the  peri- 
neum. 

"The  ulceration,  continuing  upon  the  rectum,  formed  two  fistu- 
lous  openings  into  the  gut,  four  lines  from  each  other,  and  one 
inch  and  a  half  from  the  verge  of  the  anus.  The  recto-vaginal 
fistulas  were  circular,  two  lines  in  diameter,  and  passed  through 
the  anterior  face  of  the  bowel.  The  fluid  contents  of  the  in- 
testine passed  constantly  through  those  fistulse  into  the  cavity 
behind  the  fourchette,  and  from  this  into  the  vagina,  and  also 
through  the  perineal  fistulas,  keeping  her  clothes  constantly 
soiled.  Half  an  inch  above  the  fistulas  the  gut  was  strictured,  so 
that  at  times  it  was  difficult  to  pass  the  fasces  except  in  small 
ribband-like  portions.  The  disease  had  assumed  the  secondary 
form. 

"She  had  had  large  superficial  cutaneous  ulcers  on  her  legs, 
which  left  copper -colored  and  brassy  marks,  her  back  was 
covered  about  half  its  size  with  small  superficial  ulcers,  scabs 
and  copper-colored  eruptions.  There  was  a  large  fetid  ulcer  in 
her  mouth,  at  the  junction  of  the  jaws,  near  the  right  lateral 
half-arch  of  the  palate.  Her  breath  was  fetid,  skin  pale  and 
sallow,  and  her  vital  powers  much  exhausted.  The  fistulas  were 


RECTO-VAGINAL    FISTULA.  153 

morbidly  irritable  and  discharging  ichorous  pus.  The  above  is 
the  condition  in  which  I  found  her  Sept.  5th,  1854. 

"  Treatment. — Alkaline  bath  with  friction,  three  times  per  week. 
R  Compound  Syrup  Stillingia  Sylvatica,  Sviij  lod.  Potassa  5j-  M. 
Take  5j  three  times  a  day.  Avoid  greasy  diet  and  stimulants. 
A_pply  to  the  eruptions  and  ulcers  on  the  back  and  legs,  after  the 
castile  soap  water,  R  Oxalic  Acid  5j,  Water  5j-  M,  once  per  day, 
follow  thirty  minutes  after  with  the  Mild  Zinc  Ointment.  Applied 
Arg.  Nit.  with  the  Porte  Caustique,  to  the  sore  in  the  mouth,  every 
morning,  until  its  fetor  was  corrected  and  was  healing.  Injected 
into  the  perineal  fistuhe  R  Sesq.-Carb.  Potassa  5ss,  Water  Sij-  M, 
until  the  irritability  had  subsided,  and  they  were  discharging 
more  healthy  pus.  I  then  forced  in  the  fistulae  cotton  completely 
charged  with  Pulv.  Zinc.  Sulp.,  until  the  openings  were  much 
dilated,  and  their  lining  membrane  disorganized.  The  parts 
became  much  inflamed  and  swollen  during  this  course  of  treat- 
ment, but  with  the  subsidence  of  inflammation  commenced  the 
healing  and  narrowing  of  the  fistulae.  This  treatment  also  cor- 
rected the  condition  of  the  ulcer  internal  to  the  fourchette  in  the 
perineum. 

"  Nov.  2d. — Administered  chloroform,  dilated  the  rectum  with  a 
jydss  speculum,  with  one  imperfect  side.  By  passing  a  curved 
probe  up  to  the  fistulas,  I  could  pass  it  through  the  rectum  against 
the  vagina,  and  by  bending  it  more,  with  a  finger  in  the  vagina,  I 
•could  pass  it  down  and  out  of  the  genital  fissure.  The  fistulous 
•canal  seemed  to  pass  through  the  cellular  tissue,  between  the  vagina 
and  rectum,  from  the  vaginal  ulcer  to  the  openings  through  the 
rectum.  I  then  inserted  a  probe-pointed  bistoury  up  the  specu- 
lum, introduced  the  point  into  the  fistula,  and  cut  the  edges  all 
around,  trimming  off  the  lining  membrane  until  it  bled  freely, 
then  with  a  firm  curved  needle,  six  lines  in  length,  armed  with  a 
ligature  of  silk,  I  took,  (with  a  pair  of  firm-bladed  forceps,)  two 
sutures  in  each  opening,  and  with  perforated  shot  on  each  side  of 
the  holes,  I  compressed  the  ligatures  and  approximated  the  sides 
closely,  kept  the  patient  quiet  for  seven  days,  and  though  the 
holes  were  much  less  in  size,  yet  there  was  some  oozing  through 
vthem.  My  object  in  attempting  to  close  the  recto-vaginal  fistulae 


154  DISEASES     OF     WOMEN. 

before  the  perineal,  was  to  prevent  any  matter  from  the  bowel 
passing  into  the  perineal  fistula,  and  thus  preventing  them  from 
closing. 

"  Nov.  20th. — Administered  chloroform,  and  finding  that  I  could 
not  work  to  advantage  through  the  rectum,  I  dissected  up  nine 
lines  of  the  vagina  from  the  rectum,  commencing  at  the  cavity 
formed  at  the  fourchette  by  the  previous  ulceration,  and  extend- 
ing in  the  direction  of  the  uterus.  This  exposed  the  fistulous 
openings  completely.  The  parts  were  too  tense  to  bear  a  clamp- 
suture  without  forming  fistula  to  correspond  with  the  needle- 
perforations  in  the  gut ;  and  so,  after  trimming  the  edges  freely 
with  a  bistoury,  I  approximated  them  by  taking  sutures  in  the 
adjacent  parts,  and  turning  the  bleeding  surface  of  the  adjoining 
tissues  into  the  fistulous  openings,  and  sewing  them  together  by 
stitches  taken  through  the  whole  mass. 

"I  gave  her  orders  to  keep  the  thighs  approximated  for  one 
week,  and  to  have  her  urine  drawn  with  a  catheter  every  day. 

"  Dec.  2d. — Cut  out  the  sutures.  The  parts  have  approximated, 
no  fluid  having  passed  through  ;  parts  closed  ;  perineal  fistula 
healing.  Patient  is  doing  well. 

"  Dec.   12th. — Still  doing  well ;  parts  seem  firm,  no  secretion 
passing  through. 

"  The  walls  of  the  rectum  seemed  so  tense,  that  I  found  it 
extremely  difficult  to  find  loose  material  enough  in  them  to  allow 
of  the  approximation  and  retention  in  situ  of  the  sides  of  the 
fistula,  and  so  I  turned  the  raw  surface  of  the  adjacent  tissue 
into  the  openings,  and  completed  my  operation  by  anaplasty." 

LACERATION  OF  THE  VAGINA. 

293.  Laceration  of  the  vagina  may  be  caused  by  forcible 
expulsive  efforts  during  labor,  or  by  the  improper  or  careless  use 
of  instruments.  The  laceration  may  be  complete,  the  whole  of 
its  coats  giving  way.  and  forming  an  opening  either  into  the 
bladder  in  front,  the  rectum  behind,  or  into  the  abdominal  cavity 
above  ;  or  incomplete,  the  laceration  affecting  the  mucous  mem- 
brane,  or  it  and  the  middle  coat.  Either  of  these  forms  may  or 
may  not  be  accompanied  with  laceration  of  the  perineum. 


LACKHATIOX     OF     THE     VAGINA.  155 

294.  Complete  laceration    of  the  vagina,  either  of  its  anterior 
or  posterior  walls,  has   been   already  referred  to  under  the  head 
of  recto  and  vesico-vaginal  fistula.     Rupture  of  the  upper  portion 
of  the  vagina  into  the  cavity  of  the  abdomen  is  of  extremely  rare 
occurrence.     This   accident  would  be  very  dangerous,  producing 
peritonitis,  and  should   be  treated  on  general  principles.     It  is  to 
the    incomplete    lacerations,    and    the    importance    of    an    early 
attention  to   them,  that  I  wish  to  draw  attention.     In  all  cases 
where  rigidity  of  the  soft  parts  exists,  especially  in  first  labors,  a 
careful   examination   should  be  made  after  the  birth  of  the  child, 
in  order    to  detect   this   lesion,  if    it   exists.      According  to  Dr. 
Ramsbotham,  the  medical  attendant  may  perhaps  be  sensible  that 
a  laceration  has  occurred,  but  it  may  take  place  when  neither  the 
medical  man  or  the  patient  is  at  all  aware  of  what  has  happened, 
the  pain  Avhich  the  parts  are  suffering  being  but  little  increased 
by  the  fibers  giving  way.     After  the  birth  of  the  child,  inflam- 
mation will   supervene,  and  a  cicatrix  form  in  the  place  of  the 
rupture.      If  the  laceration  is  considerable,  especially  if  there  be 
two  or  more,  the  subsequent   cicatrization  may  produce  such  a 
contraction  of  the  vagina  as  to  prevent  sexual  intercourse,  or,  if 
this  is  not  the  case,  it  will  prove  an  impediment  in  succeeding 
labors. 

295.  The  treatment  of  these  cases  consists  in  introducing  oiled- 
lint  into  the  vagina,  in  order  to  prevent  contraction  of  its  canal, 
and  the  application  of  poultices  to  the  vagina  to  subdue  inflam- 
mation, if  it  should  be  severe. 


156  DISEASES     OF     WOMEN 


CHAPTER    VI. 


LACERATION,  OR  RUPTURE  or  THE  PERINEUM. 

296.  This  accident,  when  severe,  is  one  of  the  most  distressing 
lesions  consequent  on  labor,  and  though  it  is  of  comparatively 
unfrequent  occurrence,  yet  it  deserves  the  careful  consideration  of 
the  student  and  practitioner.     Slight  lacerations  of  the  perineum 
are  of  frequent  occurrence  in  first  labors;  this  does  not,  however, 
produce  much  inconvenience,  as  the  parts  generally  heal  without 
assistance.     From  this  slight  degree  of  laceration,  we  may  have 
it  varying  in  extent,  to  the  entire  destruction  of  the  perineum, 
extending  through  the  sphincter  ani,  and  laying  the  cavities  of  the 
vagina  and  rectum  into  one. 

297.  Mr.   Baker   Brown   notices   four   varieties    of    ruptured 
perineum.    "1st.  That  in  which  the  perineum  is  torn  to  the  extent 
of  an  inch  or  less  from  the  fourchette.     This  degree  of  injury  is 
one  of  no  great  moment ;  it  is  little  marked  when  the  parts  return 
to  their  quiescent  or  normal  state,  and  requires  no  special  treat- 
ment.    2d.  Where  the  perineum  is  torn  between  the  constrictor- 
vaginae  and  sphincter  ani,  those  muscles  remaining  intact.     This 
is  actually  a  perforation  of  the  perineum,  and  in  some  rare  cases 
has  given  passage  to  the  child.    3d.  Where  the  laceration  occupies 
the  entire  length  of  the  perineum,  but  does  not  penetrate  the 
sphincter  ani.    4th.  Where  it  extends  so  as  to  divide  the  sphincter 
ani,  and  even  the  recto-vaginal  septum.    It  is  this  last  form  which 
constitutes  so  heavy  a  calamity  to  the  patient,  and  has  hitherto 
been  found  so  little  amenable  to  treatment." 

298.  The  causes  favoring  or  producing  rupture  of  the  perineum 
are,  according  to  Dr.  Churchill,  "any  deviation  from  the  ordinary 
mechanism  of  parturition ;  from  mal-conformation  of  the  passage 
or  soft  parts ;  from  mal-presentation,  or  from  mismanagement." 

The  causes  favoring  or  producing  rupture  are, 

1st.  If  the  sacrum  be  too  perpendicular,  the  head  of  the  child, 


RUPTURE     OF     THE     PERINEUM.  157 

instead  of  receiving  a  direction  anteriorly  in  the  line  of  the  axis 
of  the  lower  outlet,  will  be  forced  downward  upon  the  posterior 
portion  of  the  perineum. 

2d.  If  the  arch  of  the  pubis  be  too  acute,  so  as  to  prevent 
the  presenting  portion  filling  its  upper  part,  extraordinary  dilata- 
tion of  the  orifice  of  the  vagina  will  be  necessary,  and  the  head 
will  be  pressed  with  unusual  force  upon  the  anterior  part  of  the 
perineum. 

3d.  A  similar  effect  is  said  to  be  caused  by  a  thickened  state 
of  the  urethra  and  circumjacent  parts,  in  the  arch  of  the  pubis. 

4th.  The  too  rapid  passage  of  the  head  may  be  attended  with 
this  accident.  This  may  depend  upon  the  extraordinary  violence 
of  the  pains,  or  the  small  size  of  the  head,  which  prevents  its 
receiving  the  successive  changes  of  direction  from  the  plane 
surfaces  of  the  pelvis,  and  the  changes  in  the  axis  of  the  cavity 
and  lower  outlet. 

5th.  Exostosis  in  any  part  of  the  pelvic  cavity  may  so  act  upon 
the  direction  in  which  the  foetal  head  is  propelled,  that  rupture  of 
the  perineum  may  result. 

6th.  Excessive  breadth  of  the  perineum,  by  receiving  the  force 
of  the  descending  head  in  its  center,  may  be  a  cause  of  laceration, 
because  the  head  rests  in  the  center,  and  distends  it,  instead  of 
gliding  forward  to  the  anterior  edge. 

7th.  Rigidity  of  the  perineum,  or  an  old  cicatrix,  may  resist  the 
dilating  power  of  the  head,  and  ultimately  give  way  under  the 
employment  of  greater  force. 

8th.  The  tissue  of  the  perineum  may  be  weakened  by  disease, 
or  by  too  much  pressure,  so  as  to  offer  little  or  no  resistance. 

9th.  Mai-position  of  the  child's  head,  by  presenting  a  longer 
diameter  than  usual  to  the  lower  outlet,  may  give  rise  to  this 
accident. 

10th.  Mai-presentations. — Face  presentations,  involving  the 
passage  of  the  head  in  its  longest  diameter  over  the  perineum ; 
breech  or  footling  cases,  which  do  not  receive  a  proper  direction  so 
readily  as  the  head,  may  also  lacerate  the  perineum. 

llth.  The  accident  may  arise,  from  the  woman  being  placed 
awkwardly  for  delivery,  or  from  her  starting  away  from  the 


158  DISEASES     OF     WOMEN. 

attendant,  or  from  her  exerting  too  much  force  at  the  time  the 
head  passes  through  the  lower  outlet. 

12th.    The  perineum  may  be  torn  in  consequence  of  want  of 

•care,  when  instruments  are  used.     They   ought  generally   to  he 

emoved  just  before  the  head  passes  through  the  vaginal  orifice. 

299.  From  a  consideration  of  the  causes  above-named,  it  will 
seem,  that  no  care  on  the  part  of  the  accoucheur  can  prevent  this 
laceration  in  many  cases.     If  the  causes  named  in  Articles  1.  2, 
and  3,  exist,  they  may  be  remedied  by  the  application  of  the  hand 
in  such  a  manner  as  to  give  a  forward  direction  to  the  head.      In 
order  to  prevent,  as  far  as  possible,  the  occurrence  of  laceration, 
from   a  too  rapid  passage  of  the  head  of  the  child,  the  patient 
should  be  told  to  moderate  her  expulsive  efforts,  when  the  head  is 
distending  the  vulva,  and  not  to  bear  down  more  and  more,  as  is 
always    recommended  by  the  attendants  present,   and    by  most 
obstetricians.      Rigidity  of  the  perineum  may  be  overcome  by  the 
use  of  fomentations  of  hops  and  lobelia,  applied  as  hot  as  can  be 
borne,  and  the  internal  administration  of  tincture  of  Lobi-lia  Seed. 
The  other  causes  of  laceration,  may  be  prevented  in  most  cases,  by 
having  the  patient  placed  in  a  proper  position,  and  by  affording 
a  proper  support  to  the  perineum.     As  many  conflicting  opinions 
prevail,  as  to  the  propriety  of  supporting  the  perineum,  the  ques- 
tion arises,  how  shall  it  be  supported  so  as  to  prevent  laceration? 

300.  Dr.  Tyler  Smith  says  on  this  subject,  "some  years  ago,  I 
pointed   out  that  pressure   on  the  perineum  excited  reflex   con- 
tractions of  the  uterus — a  point  which  is,  I  believe,  now  pretty 
generally  recognized,  and  I  grounded  upon  this  circumstance,  and 
upon  the  facts  that,  in  cases  Avhere  pressure  or  support  is  most 
assiduously  rendered,  laceration  sometimes  occurs,  while  it  rarely 
happens  when  women  are  delivered  by  themselves,  an  objection 
to  the  constant  and  sustained  support  to  the  perineum,  during  the 
latter  part  of  labor.     I  believe  that  long-continued  pressure  tends 
to  produce  the  accident,  by  increasing  the  expulsive  pains  and  by 
damaging  the  perineum  itself.     We  read  of  cases  in  which  the 
perineum  was  supported  for  many  hours   in  succession;    which 
must  always  be  unnecessary,  since,  if  the  pains  are  strong  enough 
to  threaten  laceration,  the  expulsive  stage  could  not  last  the  time 


CONSEQUENCES    OF     RUPTURED     PERINEUM.      159 

•described.  My  advice  with  regard  to  the  perineum  is,  that  the 
fore-finger  of  the  left  hand  should  be  kept  upon  the  anterior 
margin  of  the  perineum  during  the  last  pains,  and  the  right  hand 
upon  the  head,  with  a  view  to  ascertain  the  moment  when  the 
perineum  is  distended  to  a  dangerous  extent,  with  one  hand,  and 
at  the  same  moment  to  retard  the  advance  of  the  head  with  the 
other.  The  head  should  be  pressed  in  passing,  close  to  the  pubis, 
so  as  to  sustain  the  perineum  as  much  as  possible.  If  we  prevent 
the  rapid  passage  of  the  head,  we  do  more  to  prevent  laceration, 
than  can  be  accomplished  by  the  most  careful  pressure." 

CONSEQUENCES  OF  RUPTURED  PERINEUM. 

301.  These  will  depend  upon  the  extent  of  the  laceration  ;  thus 
if  it  be  slight,  no  ill  consequences  will  ensue ;  but  if  it  be  of  suffi- 
cient  extent  to   weaken  the  perineum,   especially   if  it  extends 
through  the  sphincter  aui,  the  results  will  be  very  serious,  leaving 
the  patient  in  a  very  pitiable  condition.     As  I  have  already  stated 
when  describing  the  perineum,  this  forms  the  center  of  suppoi't  to 
the  entire  pelvic  viscera,  giving  attachment  to  all  the  muscles  that 
form  the  floor,  and  close  the  outlet  of  the  pelvis.     It  might  be 
well   compared  to  the  keystone   of  an  arch,   the  destruction  of 
which  would  compromise  the  safety  of  the  entire  structure.     The 
perineum  forming,  as  it  does,  the  center  of  support  to  the  vagina, 
and  through  this  to  the  uterus,  antagonizing   the  action  of  the 

O  o  o 

diaphragm  and  abdominal  muscles,  and  preventing  any  downward 
displacement  of  these  organs,  can  not  be  weakened  to  any  great 
extent,  without  producing  more  or  less  displacement,  and  conse- 
quent uterine  disease.  Prolapse  of  the  uterus,  vagina,  bladder  and 
rectum,  with  all  their  attendant  consequences,  are  not  unfrequent 
results  of  this  lesion.  Again,  when  the  sphincters  are  ruptured, 
their  functions  are  lost,  the  faeces  pass  through  the  vagina  involun- 
tarily, and  the  utmost  attention  to  cleanliness  will  not  suffice  to 
prevent  the  offensive  odor,  which  renders  the  patient  an  object  of 
disgust  to  herself  and  friends. 

302.  Treatment. — Two  modes  of  treatment  have  been  adopted 
for  the  relief  of  this  difficulty.     The  first  of  these,  the  old  method, 
consisted  in  tying  the  legs  together,  keeping  the  patient  entirely 


160  DISEASES     OF     WOMEN. 

quiet,  strict  attention  to  cleanliness,  and  other  general  measures 
to  favor  the  natural  disposition  of  the  parts  to  heal.  This 
plan  of  treatment  was  very  unsuccessful,  so  far  as  an  entire 
closure  of  the  ruptured  perineum  was  concerned ;  still  by  this 
treatment  there  was  generally  some  closure  of  the  laceration,  and 
such  a  contraction  of  the  parts  concerned,  as  greatly  to  alleviate 
the  subsequent  condition  of  the  patient. 

303.  The  second  method  of  treatment  consists  in.  freshening 
the  edges  of  the  laceration,  bringing  them  together  and  retaining 
them  in  apposition  by  sutures,  and  thus  restore  the  entire  peri- 
neum ;  or  if  there  be  too  great  a  loss  of  substance  to  permit  this, 
to  transplant  sufficient  tissue   from   some   other   part,   and   thus 
restore  this  structure. 

304.  Ambrose    Pare,    the  great  innovator  on  the   stereotyped 
processes  of  ancient  surgery,  and  who  may  be  called  the  father  of 
modern  surgery,  first  pointed  out  the  applicability  of  sutures  to 
this  accident.     The  first  application  of  this  method,  of  which  we 
have  any  account,  was  performed  by  Guillemeau,  a  student  of 
Ambrose  Pare ;  he  used  the  interrupted  suture,  and  was  success- 
ful.    During  the  present  century  the  operation   has  often  been 
resorted  to,  and  with  a  variable  degree  of  success. 

305.  This  subject  has  been  studied  with  great  care  by  that 
distinguished  German  surgeon,   Dieffenbach  ;    he   lays  down   the 
following  rules  of  practice ;  "  1st.    That  prior  to   the  operation 
the  bowels  should  be  well   cleared  by  purgatives  and   enemata. 
2d.    That  despite  the  swollen  state  of  the  torn  parts,  the  presence 
of  discharges,   and   the   debility   of  the  patient   after  labor  and 
delivery,  the  operation  should  be  performed  as  soon  as  possible 
after  the  accident,  since  these  evils  would  be  more  than  counter- 
balanced by  those  consequent  on  delay ;  as  suppuration,  slough- 
ing, and  loss  of  substance,  and  the  yet  later  results,  displacement 
of  the  uterus  and  associated  organs.     3d.    That  no  rupture,  how- 
ever slight,  should  be  left  to  nature,  for  the  healing  would  be 
superficial,  and  the  vulva  enlarged  proportionally  to  the  extent  of 
laceration,  by  the  retraction  of  the  labia  toward  the  anus,  the 
support  of  the  pelvic  viscera  being  also  thereby  diminished.     4th. 
That  three  to  five  sutures  are  necessary,  according  to  the  severity 


CONSEQUENCES    OF    RUPTURED    PERINEUM.      161 

of  the  accident ;  the  insertion  of  the  suture  commencing  at  the 
anus,  arid  where  the  sphincter  is  torn,  the  first  being  applied  at 
its  angle.  5th.  That,  where  the  perineum  is  lax,  either  the 
twisted  or  interrupted  suture  may  be  used  ;  and  when  the  vagina 
is  implicated,  its  fissure  should  be  first  brought  together  ;  also, 
that,  where  the  perineum  is  tense  and  rigid,  an  elliptic  incision 
should  be  made  on  either  side  of  the  median  line,  and  equi-distant 
from  it.  6th.  That  in  those  cases,  where  there  has  been  a  con- 
siderable loss  of  substance,  the  transplantation  of  an  adjoining 
piece  of  integument  may  be  resorted  to.  7th.  That,  in  cases  of 
old  standing,  the  edges  of  the  fissure  require  to  be  pared  before 
being  brought  in  apposition  by  sutures.  8th.  That,  after  the 
operation,  the  bowels  should  be  bound  by  the  use  of  opium,  in 
doses  of  one-third  of  a  grain  twice  a  day,  and  that  the  urine 
should  be  regularly  withdrawn  by  the  catheter." 

306.  Of  those  surgeons   who  have  performed   this   operation, 
none,  probably,  have  met  with  greater  success  than  Mr.  Baker 
Brown  of  London.     He  has  reported  eighteen  cases  of  this  acci- 
dent, in  all  of  which,  with  one  exception,  perfect  cures  resulted. 
This    fortunate    result    in    his    practice,   compared  with   the  less 
successful  practice  of  others,  would  lead  us  to  believe  that  the 
difference  in  the  mode  of  treatment,  which  he  proposes,  has  led  to 
greater  success.     No  other  author  that  I  have  seen  gives  such  a 
minute  description  of  this  operation.     I  have  therefore  given  this 
method  as  the  best  with  which  wre  are  acquainted  at  the  present  day. 

307.  "  Contra- Indications  to   Operating. — Before    deciding   on 
an  operation,  certain  circumstances  are  to  be  taken  into  account. 
For  instance,  if  pregnancy  has  advanced  beyond  the  fourth  month, 
if  suppuration  and  inflammation  exist,  then  the  operation  must  be 
delayed ;  in  the  former  case  till  after  parturition ;  in  the  latter, 
until  the  arrest  of  these  processes.     The  presence  of  leucorrhea 
need  not  deter  from  operating,  when  it  can  not  be  removed  by 
simple   measures ;    a   postponement,  however,  is  desirable,  until 
after  a  menstruation.     Cough,  if  present,  should  be  relieved,  on 
account  of  the  straining  it  causes. 

"It  seems  almost  unnecessary  to  add  that,  if  the  patient's  health 
be  impaired,  an  endeavor  should  be  made  to  improve  it  before 
11 


DISEASES     OF     WOMEN. 

surgical  means  are  resorted  to ;  for  the  condition  of  the  patient 
has  much  influence  over  the  success  of  the  operation. 

308.  "Time  of  Operating. — The  operation  maybe  performed 
immediately  after  the  completion  of  labor.  The  surfaces  of  the 
wound  are  then  fresh,  and  in  a  condition  favorable  to  union  by 
the  first  intention,  and,  consequently,  the  paring  of  the  edges 
required  in  old  cases  is  not  here  necessary.  Should,  however, 
surgical  means  not  be  resorted  to  on  the  day  of  delivery,  the 
advantages  accruing  from  the  recent  nature  of  the  wound  will  be 
lost ;  the  mischievous  effects  of  the  vaginal  discharges  will  have 
placed  the  edges  in  a  disadvantageous  position  for  healing,  and  it 
will  therefore  not  be  desirable  to  attempt  an  operation  until  after 
the  third  month,  by  which  time  the  parts  will 
have  recovered  themselves,  be  capable  of  un- 
dergoing the  necessary  denudation,  and  be 
sufficiently  strong  to  carry  the  sutures. 

309.  "As  immediately  preparatory  measures, 
the   bowels    should    be    well    cleared    out    by 
aperients ;  such  as  ox-gall  or  castor  oil,  and  by 
injections  of  salt  and  water.     Warm  baths  are 
not  objectionable  ;  but,  generally,  sponging  with 
warm  water  is  sufficient.      The  diet,  for  some 
days  prior  to  the  operation,  should  be  unstimu- 
lating,  plain,  and  nutricious.     As  a  last  point, 
the  bladder  should  be  emptied. 

310.  "Instruments  required,  are  a  common 
straight    scalpel,    a     blunt,    pointed,    straight 
bistoury  to  divide  the  spincter,  a  pair  of  long 
dissecting  forceps,  three  large  needles  for  deep 
sutures,  small   ones  for  the   superficial,  inter- 
rupted sutures,   a   tenaculum,  pieces  of  gum- 

Fia.  15.  elastic    catheter    or   bougie,    with    twine    well 

CURVED  NEEDLES,      waxed,  Sponges,  etc. 

For  the  Introduction  of  the  '  .,         . 

deep  sutures.  "  The  needles  used  lor  deep  sutures  are  fixed 

in  handles,  and  more  or  less  curved,  to  adapt  them  to  different 
cases ;  the  width  of  perineum  and  the  thickness  of  the  tissues 
varying  considerably  in  different  persons. 


CONSEQUENCES      OF      RUPTURED      PERINEUM.     1G3 

311.  "Chloroform. — The    operator    will    require   at   least    two 
assistants.     Unless  contra-indicated  or  opposed  by  the  patient  or 
her  friends,  it  is  desirable  to  place  the  patient  under  the  influence 
of  chloroform  ;  for  not  only  will  she  thereby  be  saved  pain,  but 
opposition  and  straining  are  avoided,  and  a  favorable  relaxation 
of  the  parts  obtained. 

312.  '•'•Mode  of  Operating, — The   patient  should  be   placed  in 
the    position  for  lithotomy:    the  knees  well  bent  back  upon  the 
abdomen,  and  all  hair  closely  shaven  off   about    the   parts.      The 
sides  of  the  fissure  should  be  held  by  an  assistant,  so  as  to  insure 
sufficient  tension  for  the  operator;  a  clean  incision  is  now  to  be 
made,  about  an  inch  external  to  the  edges  of  and  equal   to  the 
fissure    in    length,   and    sufficiently    deep   to    reflect    inward    the 
mucous  membrane,  and  so  to  lay  bare  the  surface  as  far  as  another 


FIG.  16. — OPERATION  FOR  RUPTURED  PERINEUM. 

incision  on  the  inner  margin.  The  denudation  of  the  opposite 
side  of  the  fissure  is  then  to  be  practised  in  a  similar  manner,  and 
the  mucous  membrane  from  any  intermediate  portion  of  the  recto- 
vaginal  septum  is  to  be  also  pared  away. 


164  DISEASES      OF      WOMEN. 

313.  "  This  denudation  must  be  perfect,  for  the  slightest  rem- 
nant of  mucous  membrane  will  most  certainly  establish  a  fistuloua 
opening  when  the  rest  of  the  surfaces  have  united. 

"  Some  operators,  especially  continental,  remove  the  mucous- 
membrane  by  scissors,  but  this  is  a  clumsy  and  unsafe  method,  and 
the  knife  will  be  found  to  effect  the  purpose  quicker  and  better. 

314.  "Division  of  the  Sphincter. — So  soon  as  this  stage  of  the 
operation  is  completed,  the  sphincter  ani  is  to  be  divided  on  both 
sides,  about  a  quarter  of  an  inch  in  front  of  its  attachment  to  the 
os  coccygis,  by  an  incision  carried  outward  and  backward.     The 
incision    should   be  made   by  a  blunt-pointed  straight   bistoury, 
which  having  been    introduced  within  the  margin  of  the  anus, 
guided  by  the  fore-finger  of  the  left  hand,  is  quickly  and  firmly 
carried  through  the  fibers  of  the  muscle  and  through  the  skin  and 
subcutaneous  areolar  tissue  to  the  extent  of  an  inch,  or  even  two, 
external   to  the    anal   orifice.     The    degree  of   relaxation  to   be 
sought  must  be  regulated  by   the   extent  and  character  of  the 
laceration  ;  it  being  remembered  that  the  freer  the  incision  the 
greater  will  be  the  amount  of  relaxation  obtained.     In  every  case, 
muscular  traction  must  be  destroyed,  for  so  long  as  it  exists  it  will 
oppose  the  union  of  the  parts. 

315.  "Insertion  of  the  Quill  Sutures. — The  sphincter  having 
been    divided  in   the  manner  just  stated,  the    thighs   are  to  be 
approximated  and  the  quill  sutures  introduced.     The  left  denuded 
surface  and  tissues  external  to  it  being  firmly  grasped  between 
the  fore-finger  and  thumb  of  the  left  hand,  a  strong  needle  carrying 
a  double  thread  is  plunged,  with  the  right  hand,  through  the  skin 
and  subjacent  tissue   an  inch  external  to  the   pared  surface,  and 
thrust  downward  and  inward  beneath  it  until  its   points  reappear 
on  the  edge  of  that  surface ;  it  is  then  introduced  at  the  corres- 
ponding margin  of  the   denuded  space  of  the   opposite  side,  and 
made  to  traverse  beneath  it  in  a  direction  upward  and  onward  until 
it  escapes  at  a  point  equi-distant  from  the  external  margin  with 
that  at  which  it  entered  on  the  left  side.     Each  of  the  three 
sutures  is  to  be  introduced  in  the  same  way,  the  one  nearest  the 
rectum  first. 

The  sutures  are  double,  to  allow  them  to  enclose  the  quills,  or 


CONSEQUENCES  OF  RUPTURED  PERINEUM.  165 

(as  actually  used)  the  pieces  of  elastic  catheter  or  bougie,  around 
which  they  loop  on  one  side,  and  are  tied  over,  by  their  free  ends, 
on  the  other.  For  sutures  I  prefer  stout  twine,  well  waxed,  to 
silk,  as  I  believe  it  to  be  less  irritating  and  productive  of  less 
suppuration. 

316.  "  Insertion  of  Interrupted  Sutures. — Having  firmly  secured 
the  three  sutures  upon  the  bougies,  the  sides  of  the  fissure  become 
approximated  —  the  denuded  surfaces  in  apposition.  To  bring 
together  the  outer  margins,  along  the  line  of  the  skin,  it  is  advis- 
able to  pass  three  or  four  interrupted  sutures.  If  this  be  carefully 
done,  union  of  the  skin  will  speedily  take  place,  and  that  of  the 
deeper  parts,  be  materially  facilitated.  As  an  accessory  or  super- 
ficial suture,  the  twisted  form  is  used  on  the  continent ;  but  I  think 
the  interrupted  more  simple,  and  have  found  it  answer  completely. 


FIG.  17. — COMPLETION  OF  THE  OPERATION. 

317.   "I  should  recommend,  previously  to  bringing  the  opera- 
tion to  a  close,  that  the  fore-finger  of  the  right  hand  should  be 


166  DISEASES     OF     WOMEN. 

passed  into  the  vagina,  and  that  of  the  left  in  the  rectum,  so  as  to 
ascertain  that  apposition  is  complete  throughout. 

"Lastly,  the  parts  having  been  well  cleansed  by  sponging  with 
cold  water,  a  piece  of  lint  steeped  in  cold  water  is  applied,  and 
over  it  a  napkin  kept  in  situ  by  a  T  bandage. 

319.  "  Operation   in  recent    cases. — The    operation  has    been 
detailed  with  reference  to  cases  of  some  standing,  where  cicatriza- 
tion has  occurred ;  with  respect  to  recent  cases  of  the  accident, 
the  only  variation  of  the  plan  is  in  the  omission  of  the  otherwise 
necessary  denudation  of  the  margins  of  the  fissure. 

320.  "  After  treatment. — The  patient  having  been  removed  to 
her  bed,  should  be  placed  on  her  left  side,  on  a  water  cushion,  with 
the  thighs  and  knees  close  together,  and  flexed  on  the  abdomen. 
Perfect  quiet  enjoined,  and  cold-water  dressing  to  be  continued. 
Ice  given  to  suck  for  twenty-four  hours,  is  refreshing,  and  allays 
febrile    reaction   and  nausea.     Two   grains  of    opium   should  be 
given  at  once,  and  one  grain  repeated  every  four  or  six  hours. 
Beef  tea  and  Arrowroot  may  be  given  within  the  first  twenty-four 
hours,  but  not  wine,  unless  there  are  signs  of  flagging;  the  wine 
I  give,  is  port.     After  the  first  day,  four  ounces  of  wine  may  be 
allowed;  and  a  generous  diet — chops,  strong  beef  tea,  etc.,  after 
the  second  or  third  day.     This  is,  supposing  no  symptoms  occur 
to  centra-indicate  such  regimen. 

321.  u  It  is  of  great  importance,  to  draw  off  the  urine  by  the 
catheter,  every  four  or  six  hours,  for  three  or  four  days  after  the 
operation.     As  the  patient  lies  in  the  obstetric  position,  this  is 
best  done  by  introducing  the  catheter  between  the  thighs,  from 
behind ;  and  in  withdrawing  the  instrument,  the  thumbs  should  be 
kept  on  its  end,  in  order  to  prevent  any  urine  remaining  in  it 
from  escaping  into  the  vagina,  whereby  it  might  cause  such  irri- 
tation about  the  wound,  as  to  render  our  attempts  to  close  it 
abortive. 

322.  "  After  some  days,  as  on  the  eighth  or  ninth  day,  if  the 
healing  go  on  satisfactorily,  and  the  strength  of  the  patient  be 
equal  to  it,  she  may  be  allowed  to  pass  water,  resting  on  the 
Hands  and  knees,  so  as  to  prevent,  as  far  as  possible,  its  contact 
with  the  lower  or  sutured  surfaces  of  the  vasina. 


CONSEQUENCES    OF     RUPTURED    PERINEUM. 

323.  "  The  deep   sutures   should  be   removed  on   the  third  or 
fourth  day  in  hospital  patients;  in  private  cases,  on  the  fifth  or 
sixth.     I  have  found  their  retention,  after  the  periods  named,  of 
no  service,  but  rather  mischievous,  by  their  tendency  to  suppurate 
and  slough,  results   of  more  rapid  occurrence  in  hospitals   than 
elsewhere ;  hence  the  earlier  date  proposed  in  hospital  cases.      On 
the  sixth  or  seventh  day,  the  external  sutures  may  be  taken  away 
In  withdrawing  the  sutures,  care   must   be  taken  not  to  separate 
the  thighs,  for  it  is  necessary  to  keep  up  their  apposition  for  some 
time.     The  time  for  the  removal  of  sutures  above  stated,  does  not 
correspond    with    my   practice    in    the    first    cases    I   published; 
increased  experience  has  led  to  the  alteration. 

324.  "  If,  after  the  operation  there  should  be  any  considerable 
bleeding  not  controlled  by  the  simple  water-dressing,  pieces  of  ice 
may  be  introduced,  or  ice  water  injected  into  the  vagina ;  other 
measures,   as  ligatures  and  torsion,  are   scarcely  ever  required. 
For  removing  secretions  and  keeping  the  parts  clean,  injections 
of  tepid  water  may  be  used  two  or  three  times  daily,  especially 
after  the  employment  of  the  catheter.     By  such,  and  by  frequent 
sponging,  perfect  cleanliness  must  be  attained.     Should  there  be 
an   offensive   discharge,    chloride   of   soda    may  be    added.     The 
opium  should  be  persevered  with,  so  as  to  keep  the  bowels  consti- 
pated for  two  or  three  weeks  after  the  parts  are  united ;  when 
union  has  become  firm  and  complete,  the  bowels  may  be  relieved 
with  injections  of  warm  water,  with  castor  oil,  and  by  the  latter, 
given  by  the  mouth.     Attention  should  be  paid  during  the  pas- 
sage of  the  first  evacuation,  and  support  given  to  the  restored 
perineum,  if  any  hardened  masses  should  cause  stretching. 

325.  "  The  precise  time  for  opening  the  bowels  must  be  regu- 
lated by  the  strength  of  adhesion  set  up,  and  by  the  amount  of 
reparation  of  lost  tissue  which  has  been  attempted. 

"  For  some  few  days  after  the  first  evacuation,  an  enema  had 
better.be  continued. 

326.  "  Should  adhesion,  unfortunately,  from  any  accident,  not 
be  complete  throughout,  and  a  fistulous  opening  persist,  the  actual 
cautery  is  the  quickest  and  surest  method  of  closing  it,  or  th 
application  of  a  caustic  or  stimulating  substance  may  be  applied.' 


168  DISEASES     OF     WOMEN. 


CHAPTER    VII. 


PELVIC  CELLULITIS — INFLAMMATION   OF   THE  CELLULAR  TISSUE 
OF  THE  PELVIS. 

327.  Between  the  intestinal,   genital,   and  urinary  canals,  and 
between    the    facia   pelvica    and    the    parts  invested   by    it,    and 
between  the  two  folds  of  peritoneum  forming  the  broad  ligaments, 
there  exists  an  abundant   quantity   of   cellular  tissue,   which    is 
liable  to  inflammation  and  all  its  terminations,  the  same  as  cellular 
tissue  in  any  other  part  of  the  body.     This  inflammation  is  not 
of  unfrequent  occurrence  as  a  consequence  of  parturition,  and 
the   extension   of  inflammatory   action   from   the  uterus  and  its 
appendages,  and  from  other  causes.     Though  it  can  not  be  said  to 
be  a  very  fatal  affection,  even  when  it  terminates  in  suppuration, 
yet,  in  many  instances,  it  is  of  long  continuance,  greatly  affecting 
the  general  health,  and  it  sometimes  terminates  in  the  formation 
of  very  distressing  fistulas. 

328.  The  seat  of  the  inflammatory  process  varies  in  different 
cases ;    thus,  it   may  be   confined   to  the    cellular  tissue,  lying 
between  and  connecting  the  vagina  and  rectum  ;  to  that  situated 
on  each  side  of  the  vagina,  between  it  and  the  lateral  walls  of  the 
pelvis ;    to   that    lying   between   the   two   layers   of  the   broad 
ligaments ;  and  in  some  rare  cases  it  may  arise  in  the  cellular 
tissue  connecting  the  vagina  and  cervix   uteri   to  the  bladder. 
When  inflammation  attacks  the  broad  ligaments,  it  is  a  difficult 
matter  to  tell  whether  the  inflammatory  process  is  confined  to  the 
cellular  tissue,  or  extends  to  the  ovaries  and  fallopian  tubes. 

329.  Causes. — Pelvic  cellulitis  is  probably  of  more  frequent 
occurrence  as   a   result   of  labor,  than  from  any   other  cause ; 
either  as  a  consequence  of  the  severe  and  long-continued  pressure 
of  the  child's  head  on  the  tissues  of  the  pelvis,  or  as  the  result 
of  puerperal   inflammation.     It   may,  however,  follow  ordinary 


PELVIC    CELLULITIS. 

labor.  It  may  occur  a  considerable  time  after  labor,  or  it  may 
attack  these  tissues  independent  of  the  puerperal  state,  in  married 
women,  or  in  the  unmarried.  In  these  last  cases,  it  may  result 
from  the  extension  of  an  inflammation  of  the  uterus,  fallopian 
tubes,  ovaries,  and  vagina  ;  or,  as  the  result  of  some  violence 
done  the  parts,  as  by  a  fall,  a  kick,  a  blow,  etc.;  or  like  inflam- 
mation of  other  parts,  from  exposure  to  cold,  atmospherical 
vicissitudes,  etc. 

330.  Terminations. — This  inflammation,  after  giving  rise  to 
great  swelling  and  induration,  by  the  effusion  of  serum,  coagu- 
lable  lymph,  etc.,  not  unfrequently  terminates,  under  judicious 
treatment,  in  resolution,  the  inflammatory  product  being  entirely 
absorbed,  and  the  parts  left  in  their  normal  condition.  Or  it 
may  assume  a  sub-acute  or  chronic  form,  the  inflammatory 
product  becoming  organized,  and  the  mass  of  cellular  tissue 
hypertrophied ;  in  this  case  it  may  give  rise  to  morbid  adhesions 
between  the  uterus  and  the  walls  of  the  pelvis,  or  between  the 
ovaries  and  fallopian  tubes,  and  the  other  pelvic  viscera,  or  the 
walls  of  the  pelvis,  producing  unnatural  immobility  of  these 
organs,  and  the  serious  train  of  consequences  that  arise  from 
this  condition ;  or  it  may  terminate  in  suppuration,  and  the 
formation  of  a  pelvic  abscess.  This  abscess  may  point  and  dis- 
charge itself  into  the  vagina,  which  is  its  most  frequent  course ; 
into  the  rectum ;  it  may  pass  down  by  the  side  of  the  rectum  and 
open  externally ;  it  may  open  and  discharge  itself  into  the 
bladder,  the  pus  passing  off  through  the  urethra  ;  through  the 
uterine  walls  into  the  cavity  of  the  uterus ;  into  the  peritoneum ; 
or  if  it  is  situated  in  the  broad  ligaments,  it  may  discharge  itself 
externally,  through  the  abdominal  parieties  covering  the  tumor; 
the  discharge  of  the  abscess  into  the  bladder  or  uterus  is  very 
uncommon,  but  few  cases  being  reported.  Its  discharge  into  the 
peritoneum  is  very  rare,  and  as  this  would  give  rise  to  severe 
peritonitis,  its  occurrence  would  be  always  dangerous.  The 
matter  may  be  evacuated  by  any  of  these  routes,  and  if  the 
opening  be  sufficiently  large,  the  sac  will  be  emptied,  and  the 
abscess  fill  up  and  heal.  But,  if  the  opening  be  small,  the  dis- 
charge may  continue  for  an  indefinite  length  of  time,  or  it  may 


170  DISEASES     OF     AVOMEX. 

form  for  itself  another  opening  into  a  different  organ  or  part. 
These  openings,  whether  one  or  more,  may  remain  fistulous,  and 
be  very  hard  to  heal. 

331.  Duration. — The  duration  of  this  disease  varies  greatly, 
according  to  the  habits,  constitution  of  the  patient,  and  to  the 
producing  cause.     Thus,  resolution  may  be  effected  in  some,  in 
from  four  to  ten  days,  while  in  others  it  may  continue  in  a  chronic 
form,  from  one  to  three  months.     The  same  difference  exists  when 
the    inflammation  has   terminated  in   suppuration.     The  average 
duration  of  the  cases  reported  by  Dr.  Lever,  was  eight  weeks, 
shortest  duration  three  weeks,  and  the  longest  thirteen  weeks. 

332.  Symptoms. — The  symptoms  of  this  affection  are  at  first 
very  obscure,  and  may  be  ascribed  to  inflammation  of  any  of  the 
pelvic  viscera.     The  commencement  of  the  inflammation  is  gener- 
ally   marked    by    considerable    constitutional    disturbance ;    the 
patient  complains  of  weariness  and  aching  in  the  limbs,  headache, 
loss  of  appetite,  etc. ;  the  pulse  is  accelerated,  considerable  thirst, 
a  dry,  constricted  state  of  the  skin,  and  a  good  deal  of  irritability 
and  restlessness.     The  patient  feels  a  constant  weight  and  drag- 
ging dowrn  in  the  pelvis,  with  pain  more  or  less  acute  at  the  seat 
of  the   inflammation,  and   which   radiates  from  this   point  in  all 
directions.      This    weight,    tension,    bearing    down,   and  pain,   is 
greatly  increased  when  the  patient  assumes  an  upright  position, 
and  most  generally  by  the  act  of  defecation ;  in  many  cases,  it  is 
extremely  difficult,  if  not  impossible,  for  the  patient  to  straighten 
the  thighs,  or  stand  quite  upright.    The  effects  of  this  inflammation 
on  the  bladder  and  rectum,  from  an  extension  of  the  irritation  to 
them,   or  from   the   pressure    arising  from   the  formation   of  an 
abscess,  sometimes  gives  rise  to  very  distressing  symptoms ;  as  a 
constant  desire  to  pass  water,  or  a  difficulty  in  passing  it,  attended 
with  pain  and  a  sensation  of  heat ;  and  frequent  and  distressing 
calls  to  evacuate  the  bowels,  which  is  sometimes  attended  with 
great  difficulty.     These  symptoms  may  continue  for  a  longer  or 
shorter  time.     If  the  disease  terminates  in  resolution,  they  will 
gradually   diminish    and    ultimately   cease;    the   tumor  becoming 
smaller   and   less    tender,  until   it    entirely   disappears.      If  the 
inflammation   terminates   in  suppuration,   there  is   a  lull  in  the 


PELVIC     CELLULITIS.  171 

general  symptoms,  the  pain  becomes  throbbing,  and  there  are 
generally  chills  of  greater  or  less  severity.  The  fever  assumes 
an  intermittent  form,  the  exacerbations  almost  always  occurring 
in  the  evening. 

333.  Diagnosis. — It  will  be  seen  that  the  general   symptoms 
given   above  are  not  sufficient  to  form  a  diagnosis,  as    they  are 
similar  to  those  produced  by  other   diseases   of   this  region ;   \ve 
have,  therefore,  to  depend  on  the  results  of  an  examination,  made 
as  heretofore  directed,  to  distinguish  the  seat  and  character  of  the 
disease.     By  means  of  an  examination  by  the  vagina,  rectum  and 
hypogastrium,  we  can  determine  exactly  the  seat  of  the  enlarge- 
ment ;  whether  iu  the  broad  ligaments,  in  the  cellular  tissue,  at 
the  sides  of  the   pelvis,  or  anterior  or   posterior   to   the  vagina; 
and  also  the  absence  of  disease  of  the  uterus,  rectum,  bladder,  and 
vagina.     Pressure  on  the  enlarged  part  is  attended  with  great 
pain,  and  there  is  a  marked  increase  in  the  natural  heat  of  the 
region.     When  an  abscess  has  formed,  if  it  is   low  down   in  the 
pelvis,  distinct  fluctuation  can  be  discovered  through  the  vagine 
or  rectum. 

334.  Treatment. — If  we  are  called  in  the   early  stage  of  the 
disease,  our  object  should  be  to  arrest  the  progress  of  the  inflam- 
mation, and  procure  resolution.     For  this  purpose  we  might  use 
the  spirit  vapor-bath  with  much  advantage,  if  the  general  health 
of  the  patient  would  permit  it ;  whether  this  be  used  or  not,  hot 
fomentations  of  hops,  of  lobelia,  or  stramonium,  should  be  applied 
over  the  lower  portion  of  the  abdomen,  and  over  the  vulva.     This 
will  afford  great  relief  to  the  patient.     The  frequent  use  of  warm 
vaginal  injections,  writh  counter-irritation,  or  dry  cupping  over  the 
lumbar  and  sacral  regions  of  the  spine,  will  also  be  of  great  use. 
With  this  I  would  administer  the  sedative,  Aconite  or  Veratrum, 
with  an}T  other  remedy  especially  indicated,  as  the  Maerotys,  Bry- 
onia,  Khus,  Phytolaeca,  etc.     In  some  cases  lime  water  exerts  an 
excellent  influence,  especially  if  the  patient  has  shown  a  tendency 
to  inflammation  of  cellular  tissue.     If,  as  in  many  cases,  the  tongue 
is  broad,  pallid  and  dirty,  I  would  advise  Sulphite  of  Soda  in  doses 
of  ten  grains  every  two  hours.     The  Hamamelis  proves  a  good 
remedy  when  the  tissues  are  full,  and  there  is  a  sense  of  dragging 


172  DISEASES    OF    WOMEX. 

in  the  pelvis.  The  Viburnum  is  indicated  when  there  is  tension 
and  expulsive  pain.  If  the  disease  progresses  slowly,  with  an 
abundant  deposit,  and  an  inclination  to  rapid  breaking  down  of 
tissue,  use  the  Uvedalia  ointment  thoroughly.  Cathartics  are 
inadmissable  in  the  most  of  cases,  their  action  producing  great 
pain,  and  a  determination  of  blood  to  the  already  congested 
tissues ;  in  the  place  of  these,  it  would  be  well  to  move  the 
bowels  once  a  day,  by  the  use  of  free  injections  of  warm  water. 
If  the  patient  was  already  debilitated  before  being  attacked  by 
this  disease,  the  general  health  should  be  improved  by  the 
administration  of  the  vegetable  tonics  and  iron. 

335.  If,  however,  in  spite  of  the  persevering  use  of  the  means 
above-mentioned,  for  three  or  four  days,  the  disease  still  continues, 
we  may  expect  that  suppuration  has,  or  will  take  place,  and  our 
object  will  then  be  to  promote  it  by  the  use  of  fomentations  and 
poultices  constantly  applied.  When  suppuration  has  taken  place, 
which  is  indicated  by  rigors,  a  dull  throbbing  pain,  and  by  the 
fluctuation  felt  on  an  examination ;  the  question  arises,  shall  we 
leave  the  discharge  of  the  abscess  to  nature,  or  open  it  in  the 
most  convenient  and  least"  dangerous  situation  ?  My  opinion  is, 
that  where  it  can  be  opened  through  the  vagina  or  rectum,  it 
would  be  better  to  do  so,  rather  than  to  run  the  risk  of  the  matter 
burrowing  in  the  tissues  of  the  pelvis,  or  opening  into  the  perito- 
neum, bladder  or  uterus.  On  this  point  Dr.  Churchill  says,  "  I 
can  not  too  strongly  impress  upon  my  readers  the  advantage  of 
making  an  opening  into  the  abscess,  when  possible,  and  so 
deciding  the  course  which  the  matter  ought  to  take,  instead  of 
leaving  it  to  burrow  and  open  in  some  inconvenient  or  dangerous 
situation.  If  we  perceive  the  thinning  and  softening  pointing  in 
the  vagina,  our  minds  may  be  easy,  providing  it  opens  freely  into 
it,  and,  in  some  cases,  the  fact  of  a  small  opening  having  taken 
place,  may  be  determined  by  examining  the  discharges  with  a 
microscope.  If  the  opening  be  not  large  enough,  we  can  easily 
make  it  larger.  An  opening  through  the  vagina,  rectum,  or 
external  parieties  is  safe  enough  and  far  better  than  the  chance  01 
an  opening  in  the  peritoneum.  Our  great  duty  is  to  see  that  the 
opening,  whether  spontaneous  or  made  with  the  lancet,  is  sufficient 


PELVIC     CKLLULITIS.  173 

to  empty  the  sac,  and  that  the  matter  is  completely  evacuated. 
Should  an  opening  form  in  an  inconvenient  or  dangerous  situation, 
we  must  meet  the  consequences  according  to  the  means  at  our 
disposal.  It  will  be  better  even  to  make  a  second  opening,  and 
freely  empty  the  sac,  rather  than  allow  a  fistulous  communication 
to  continue." 

336.  Before  we  attempt  to  open  the  abscess,  we  should  satisfy 
ourselves  positively  in  regard  to  the  contents  of  the  tumor.     For 
this  purpose,  the  exploring  needle  should  be  used,  and  the  fluid 
drawn  by  it  examined. 

337.  When  suppuration  commences,  the  diet  must  be  generous, 
and  the  patient's  strength  supported  by  a  free  use  of  stimulants, 
and  the  bitter  tonics. 

338.  The  fistulous  passages  remaining  after  the  discharge  of 
these  abscesses,  may  continue  for   an  indefinite  length  of  time. 
The  treatment  of  these  will  have  to  be  suited  to  each  particular 
case,  though  in  many  of  them  the  treatment  recommended  under 
the  heads  of  vesico  and  recto-vaginal  fistula,  will  be  applicable. 

339.  To  illustrate  the  rarer  forms  of  fistula  occasioned  by  this 
disease,  as  well  as  to  show  its  general  course,  I  give  below  the 
report   of  three   cases,   by  Dr.    Simpson.     In   the   first   of  these 
cases,  the  abscess  discharged  itself  both  through  the  bladder  and 
uterus,  forming  vesico-uterine  fistula ;  in  the  second  case,  the  dis- 
charge was  into  the  uterus  and  intestine,  forming  utero-intestinal 
fistula;  in  the  third  case,  the  abscess  opened  into  both  the  rectum 
and  bladder,  the  vagina  remaining  intact,  forming  a  recto-vesieal 
fistula.     These  cases  will  be  found  very  interesting,  as  they  illus- 
trate the  course  of  the  disease,  and  the  singular  manner  in  which 
it  sometimes  terminates. 

340.  Case  1st.  The  patient,  aged  22,  the  mother  of  two  chil- 
dren, was  admitted  into  the  female  ward   of  the  Royal  Infirmary, 
in  June  last.     Her  youngest  child  was  then  eleven  months  old, 
and   she   had    made    a    perfect    recovery    after  her    confinement 
with  it.    About  six  months,  however,  subsequently  to  her  delivery, 
she  was   seized  with  local  pelvic  pains,  dysuria,   and  the  usual 
symptoms  of  pelvic  cellular  inflammation.     Three  or  four  weeks 
after  the  commencement  of  this  attack,  she  had  shiverings  and 


174  DISEASES      OF     WOMEX. 

perspirations,  and  other  symptoms  of  hectic  fever.  These  symp- 
toms were  shortly  followed  by  evidence  of  the  escape  of  purulent 
matter,  and  subsequently,  complete  incontinence  of  urine  came 
on.  After  this,  the  urine  continued  to  be  discharged  per  vaginum, 
ip  to  the  date  of  her  admission  into  the  hospital,  four  months 
after  the  commencement  of  the  inflammatory  symptoms.  The 
urine  contained  a  considerable  quantity  of  pus.  On  examination, 
the  urethra  was  found  perfectly  patent,  although  the  urinary  secre- 
tion was  not  discharged  through  it.  There  was  still  a  considerable 
mass  of  fixed  inflammatory  deposit  in  front  of  the  cervix  uteri,  or 
in  the  cellular  tissue,  between  it  and  the  posterior  wall  of  the 
bladder.  The  cervix  uteri  itself  was  considerably  hypertrophied, 
particularly  its  anterior  lip.  That  the  urine  passed  through  the 
os  and  cervix  uteri  from  the  bladder,  was  ascertained  by  the 
simple  experiment  of  filling  up  the  os  uteri  for  a  day,  with  a 
small  sponge  tent.  During  the  time  the  cavity  of  the  os  uteri 
was  stopped  up  with  this  ping,  the  urinary  discharge  was  evacu- 
ated through  the  urethra;  but  immediately  began  again,  and  con- 
tinued to  pass  through  the  artificial  vesico-uterine  opening  as  soon 
as  the  sponge  plug  was  withdrawn.  After  withdrawing  the  plug, 
the  cervical  cavity,  which  had  been  dilated  by  its  presence,  was 
examined  by  the  finger,  and  two  apertures  were  found  passing 
into  it,  or  rather  leading  from  it :  one,  the  normal  aperture,  lead- 
ing upward  into  the  cavity  of  the  uterus,  as  ascertained  by  the 
uterine  sound:  the  other,  tending  obliquely  forward  toward  the 
cavity  of  the  bladder.  This  latter  artificial  opening  was  freely 
cauterized  by  solid  nitrate  of  silver.  Subsequently,  local  and 
general  measures  was  employed,  as  external  counter-irritation, 
iodine,  etc.,  to  promote  the  absorption  of  the  inflammatory 
deposit.  In  the  course  of  a  few  weeks,  the  swelling  from  between 
the  bladder  and  the  cervix  uteri  diminished,  the  incontinence  of 
urine  became  gradually  lessened,  and  was  ultimately  totally 
arrested;  the  cure  being,  as  I  believe,  the  result  of  the  natural 
contraction  of  the  parts,  following  upon  the  absorption  of  the 
original  inflammatory  deposit.  Subsequently,  this  poor  patient 
•was  attacked  with  symptoms  of  pulmonary  phthisis,  and  died  a 


PELVIC     CKLLULITIS.  175 

short  time  ago,   at   a   distance  in  the  country,  but  without  any 
return  whatever  of  the  incontinence  of  urine. 

341.  '•'•Case  2d. — A  lady,  a  few  days  after  her  first  confinement, 
was  attacked  with  symptoms  of  fever,  and  local  pelvic  inflamma 
tion.     These  terminated  in  a  very  tedious  pelvic  abscess.     Abou 
a  year  subsequent  to  her  accouchement  she  was  brought  to  Edin- 
burgh, and  placed  for  some  time  under  my  care.      She  still  had 
considerable  thickening  and  pain  on  pressure  in  the  left  side  of 
the  pelvis,  which  had  been  the  scat  of  the  pelvic  cellulitis.     The 
cervix  uteri,  and  indeed  the  whole  uterus,  was  elevated  upward, 
and  drawn  considerably  to  the  same  side.     On  examining  simul- 
taneously with  the  fingers  of  the  right  hand  on  the  roof  of  the 
vagina,  and  with  those  of  the  left  hand  placed  externally  over  the 
left  iliac  region,  much  thickening  and  agglutination  of  the  uterus 
and  intestines  could  be  readily  ascertained  in  the  left  pelvic  and 
iliac  regions.     Discharges  of  slight  accumulations  of  pus  recurred 
from  time  to  time  through  the  os  uteri ;  and,  occasionally,  after  these 
discharges,  small  quantities  of  feculent  matter  were  found  in  the 
vagina — showing  a  communication  to  exist  between  the  intestinal 
canal,  at  some  part,  perhaps  the  sigmoid  flexure,  and  the  cavity 
of  the  uterus.     When  the  canal  of  the  cervix  uteri  was  gently 
examined  by  a  slender  probe  or  sound,  a  fistulous  communication 
could  be  traced,  passing  up  from  the  cavity  of  the  cervix  laterally 
toward  the  left  iliac  region  ;  but  this  sinus  could  not  be  followed 
for  any  great  length. 

In  this  case  there  was  a  constant  tendency  to  the  recurrence  of 
inflammatory  attacks  in  the  original  seat  of  the  pelvic  inflamma- 
tion, some  of  which  were  extremely  severe.  The  patient  subse- 
quently removed  to  the  south  of  England,  where  she  died  under, 
I  believe,  one  of  these  renewed  inflammatory  attacks. 

342.  "Case  Sd. — The  patient,  when  about  twenty-three  years 
of  age,  and  unmarried,  was  attacked  with  fever  and  severe  local 
inflammatory  pain   in    the    pelvis    and    left    groin.     After    these 
symptoms    had    continued   for    some   weeks,    she   was   at  length 
relieved  by  the  discharge  of  a  large  quantity  of  purulent  matter 
from  the  rectum.     About  twelve  months  after  the  occurrence  of 
this  pelvic  abscess  she  was  considered  so  well  as  to  be  allowed  to 


176  DISEASES    OF    WOMEN. 

be  married.  But  from  that  time  she  suffered  from  repeated 
attacks  of  pelvic  irritation  and  inflammation,  with  leucorrhea, 
irregular  menstruation,  etc.  She  never  became  pregnant.  Several 
years  subsequent  to  marriage,  during  one  of  these  recurrent  pelvic 
attacks,  the  bladder  became  greatly  irritated ;  and  after  this 
painful  dysuria  had  lasted  some  time,  purulent  matter  was  dis- 
charged along  with  the  urine.  Subsequently  to  this  period,  and 
on  to  the  time  of  her  death,  four  years  afterward,  small  portions 
of  feculent  matter  and  flatus  passed  from  time  to  time  by  the 
urethra,  along  with  the  urine,  showing  a  communication  to  exist 
between  the  intestinal  and  urinary  canals.  As  high  up  the 
rectum  as  could  be  reached  by  the  finger,  a  fistulous  opening 
was  traceable  in  the  anterior  and  lateral  part  of  the  bowel,  and  a 
probe  could  be  passed  forward  to  some  extent  through  it.  There 
was  much  thickening  and  agglutination  of  the  pelvic  tissues  at 
that  part.  No  treatment  was  of  any  avail  in  relieving  the  patient 
from  her  distressing  symptoms.  She  died  ultimately  of  a  short 
illness  from,  as  reported  by  Dr.  Miller,  some  affection  of  the 
brain." 


GONORRHEA. 


CHAPTER    VIII. 


VENEREAL     DISEASES. 

343.  The  diseases  that  come   under  this   head  are   eminently 
contagious,  producing  the  same  affections  in  the  male.     They  are 
propagated  only  by  actual   contact,  i.e.,  by  sexual   intercourse, 
the  accidental  contact  of  the  virus,  or  by  inoculation.     Of  this 
class  of  diseases  we  distinguish  two  varieties,  neither  of  which  is 
capable  of  reproducing,  or  changing  to  the   other.     These   two 
diseases  are,  Gonorrhea  and  Syphilis. 

GONORRHEA. 

344.  Gonorrhea  in  the  female  is,  for  the  most  part,  a  disease 
of  very  different  character  from  that  affecting   the  male.     This 
difference,    however,    consists    in    the    different   location    of    the 
disease,  and    not    in  the    character  of   the    morbid  virus  which 
produces  it. 

There  can  be  no  doubt,  but  that  this  disease  arises  from  a 
specific  morbid  material  or  virus,  generated  by  the  diseased  parts, 
though  the  existence  of  this  specific  virus  has  never  been  fully 
demonstrated.  This  disease  recognizes  for  its  pathology,  acute  or 
chronic  inflammation  of  the  vulva,  urethra,  vagina,  canal  of  the 
cervix,  and  even  of  the  mucous  membrane  lining  the  cavity  of  the 
uterus,  and  of  the  fallopian  tubes.  This  inflammation,  though 
differing  but  slightly  from  the  ordinary  form,  gives  rise  to  the 
peculiar  product  by  which  it  was  produced,  and  which  will  con- 
tinue to  reproduce  the  same  specific  inflammation.  On  this 
subject  Dr.  Bennet  remarks,  "It  is  a  singular  pathological  fact, 
that,  although  the  existence  of  a  specific  and  contagious  form  of 
vaginitis  is  generally  admitted,  yet  it  is  difficult,  if  not  impossible, 
to  point  out  any  decided  characteristic,  by  which  it  may  be 
distinguished  from  ordinary  vaginitis.  Like  all  those  who  have 
12 


178  DISEASES     OF     WOMEN. 

preceded  me,  I  am  unable  to  indicate  satisfactorily,  any  absolute 
means  of  distinguishing  simple  inflammation  of  the  vagina  and 
gonorrheal  inflammation,  though  I  believe  the  difference  does 
exist."  Certainly  there  is  a  gonorrheal  virus,  although  it  can  not 
be  demonstrated.  In  the  female,  gonorrhea  is  not  confined  to  the 
urethra,  being  scarcely,  if  ever,  confined  to  that  canal,  and  in  some 
cases  not  aifecting  it  at  all ;  but  it  is  also  seated  in  the  mucous 
membrane,  reflected  over  the  neck  and  mouth  of  the  uterus,  and 
in  the  canal  of  the  cervix,  in  the  vulva,  the  vagina  and  its  follicles, 
and  the  vulvo-vaginal  glands. 
We  have  then  to  consider. 

345.  1st.  Urethral  gonorrhea,  the   type  of  the   disease   as   it 
affects  both  male  and  female,  differing,  however,  in  the  two  so  far 
as  regards  the  anatomical  structure  of  the  two  canals.     The  female 
urethra   being   much    shorter,    mere    dilatable,    and   lacking    the 
prostate  gland  and  other  appendages  of   the   male  urethra,  the 
affection  of  which  so  often  greatly  aggravates  the  disease ;    the 
consequence  of  this  difference  of  structure  is,  that  this  form  of 
the  disease  is  much  milder  in  the  female  than  in  the  male.     The 
contagious  property  of   the  virus,   secreted    by  the    urethra,  is 
said  by  some  authors  to  be  much  greater  than  that  secreted  by 
other  parts. 

346.  2d.  A  specific  inflammation  of  the  vulva  or  vagina  pro- 
ducing a  discharge,  which  will  produce  the  specific  gonorrheal 
inflammation  in  the  male ;    this  may  exist  alone,  or  it  may  be 
complicated  with  the  urethral  or  uterine  inflammation. 

347.  3d.  A  specific  inflammation  of  the  cervix  uteri,  of  its 
canal,  and  of  the  mucous  membrane  lining  the  uterine  cavity  and 
the  fallopian  tubes,  the  product  of  which  is  contagious,  reproducing 
the  same  specific  inflammation  in  the  male. 

Either  of  these  three  forms  of  disease  may  be  acute  or  chronic, 
or  complicated  with  some  other  affection  of  the  parts. 

348.  The  urethral  form  of  gonorrhea  is  rarely  met  with  alone ; 
it  is  said  that  it  scarcely  ever  occurs,  unless  complicated  with  the 
other  forms.     The  symptoms  that  present  themselves,  are  some- 
what similar  to,  though  much  milder  than  those  in  the  male.     The 
first  stage,  that  of  irritation,  comes  on  in  from  three  to  five  days 


GONORRHEA .  179 

after  connection.  The  patient  begins  to  experience  a  sensation 
of  heat,  itching,  and  general  irritation  along  the  course  of  the 
urethra,  but  more  especially  at  the  rneatus  urinarius.  As  the 
inflammation  advances,  the  orifice  of  the  urethra  Avill  be  found 
swollen  and  gaping,  and  in  some  cases  the  mucous  membrane  will 
be  slightly  everted.  The  urethra  along  its  entire  course  in  the 
anterior  wall  of  the  vagina,  will  be  found  perceptibly  enlarged, 
and  more  or  less  tender  on  touch.  If  the  finger  be  pressed  along 
the  course  of  the  urethra,  a  muco-purulent  fluid  will  exude  from 
the  mcatus  ;  as  the  inflammation  becomes  more  severe,  the  dis- 
charge will  be  more  abundant,  thick,  and  of  a  greenish-yellow 
color.  There  is  pain  in  micturition,  and  a  sensation  of  scalding 
when  the  urine  is  passed.  Sometimes  this  irritation  is  so  great, 
that  the  passage  of  the  urine  will  be  checked  or  entirely  stopped 
by  the  spasmodic  contraction  of  the  urethra.  There  is  also  a 
constant  desire  to  urinate,  but  when  the  urine  is  passed,  it  flows 
in  a  smaller  stream  and  in  smaller  quantities.  These  symptoms 
usually  continue  from  ten  to  fourteen  days,  when  the  third  stage, 
or  that  of  chronic  or  sub-acute  inflammation  sets  in  ;  during  this 
period  the  acute  inflammatory  symptoms  subside,  the  thick  yellow- 
ish-green discharge  ceases,  and  is  replaced  by  one  of  a  thin  muco- 
purulent  character.  With  the  cessation  of  the  severe  inflammatory 
symptoms,  the  swelling  of  the  urethra  is  reduced,  and  the  tender- 
ness and  pain  is  much  modified.  The  third  stage  of  the  disease 
may  continue  indefinitely  for  months  and  even  years,  the  slight 
discharge  and  tenderness  along  the  course  of  the  urethra  being 
all  the  symptoms  that  are  left  to  mark  the  existence  of  the  disease  : 
even  this  gleety  discharge  is  said  to  produce  this  disease  in  very 
susceptible  persons. 

349.  According  to  Mr.  Parker,  when  the  vulva  is  the  seat  of 
the  disease,  the  labia  majora  is  more  or  less  swollen ;  on  everting 
them,  their  internal  or  mucous  surface  is  red  or  inflamed,  uniformly 
or  in  patches ;  or,  again,  it  has  an  apthous,  patchy  appearance, 
especially  in  old  cases  ;  the  surface  is  sometimes  studded  with 
warts,  and  occasionally  the  whole  labia  are  converted  into  a  condy- 
lomatous  mass,  which  runs  backward  along  the  perineum  to  the 
margin  of  the  anus,  which  is  surrounded  by  similar  growths 


180  DISEASES     OF     TTOMEN. 

Sometimes  a  similiar  condition  of  the  mons  veneris  exists,  but  thi& 
is  comparatively  rare.  The  labia  minora  are  also  red  and  swollenr 
and  the  entrance  to  the  vagina  contracted,  red,  and  intensely 
tender  in  acute  cases ;  between  the  folds  of  the  labia,  a  white, 
sticky  secretion  is  found,  like  that  under  the  prepuce  in  balanitis 
in  the  male.  The  irritation,  itching,  and  pain  are  intolerable  in 
gonorrhea,  where  the  vulva  is  especially  affected,  particularly  in 
cases  where  a  newly  married  woman,  previously  healthy,  has  been 
diseased  by  the  husband,  who  has  married  with  an  uncured 
blennorrhea,  a  circumstance  not  very  uncommon." 

350.  When  the  vagina  is  affected  by  gonorrhea,  it  will  be  found 
contracted,  its  mucous  lining  hot,  red,  and  painful,  and  the  rugae 
red  and  elevated  ;  the  inflammation  rarely  affects  the  whole  vaginal 
surface  at  once;  that  part  under  the  pubis  being  most  frequently 
the  seat  of  the  disease.     In  from  twelve  to  forty-eight  hours  after 
connection,  the  patient  Avill  perceive  the  first  symptoms  of  the 
disease  :    a  sense   of  heat,  soreness,  and  fulness   of  the  vagina, 
and  there  will  often  be  a  thin,  colorless,  and  acrid  discharge.     In 
the   second  stage,  when    the    inflammation  is   at  its   hight,  these 
symptoms  are  all  increased ;  the  pain  is  severe,  especially  if  any 
excercise  is  taken ;  there  is  a  feeling  of  weight  and  dragging  down 
in  the  pelvis  and  lower  portion  of  the  abdomen;  the  pain  may 
extend  to  the  back  or  down  the  thighs,  and  very  frequently  the 
irritation  extends  to  the  bladder.     The  discharges  now  become 
increased  in  quantity,  and  thicker,  and  of  a  whitish,  greenish,  or 
yellowish-green    color.     In    from    eight  to    ten    days,  the    acute 
symptoms    disappear,  and    the    third   stage,  or   that   of  chronic 
inflammation  sets  in.     In   this  stage  of  the  disease,  the  vaginal 
discharge  is  generally  plentiful,  though  there  is  very  little,  if  any, 
tenderness ;  the  mucous  membrane  has  lost  its  red  appearance, 
and   is    generally   paler    than    natural ;    the    vaginal   walls   have 
generally  a  loose  and  flabby  feel.     This  condition  may  continue 
indefinitely. 

351.  The  mucous   membrane   covering   the    cervix,   may   be 
affected  with  the  vagina,  or  it  may  be  the  seat  of  a  separate  affec- 
tion ;  the  symptoms  are  similar  to  those  first  described.     The  os 
uteri  is  frequently  affected,  as  well  as  the  cavity  of  the  cervix. 


GONORRHEA.  181 

In  this  case,  the  os  will  he  found  on  examination,  to  he  dilated, 
red  and  generally  tender  to  the  touch.  The  patient  will  complain 
of  a  weight  in  the  pelvis,  pain  in  the  hack  and  in  the  ovarian 
regions.  The  symptoms  here  never  present  the  acute  form  that 
I  have  described  above.  The  inflammation  of  the  cavity  of  the 
cervix  gives  rise  to  a  more  or  less  profuse  discharge  of  the 
peculiar  transparent,  tenacious,  Avhite  of  egg  mucus,  secreted  by 
the  follicles  of  this  canal.  This  secretion  may  continue  for 
months,  retaining  its  contagious  character  to  the  last;  it  likewise 
exerts  a  greater  effect  on  the  general  health,  than  any  other  form 
of  the  disease.  Those  cases  in  which  the  gonorrheal  inflamma- 
tion extends  to  the  cavity  of  the  uterus,  or  the  fallopian  tubes,  is 
fortunately  very  rare ;  some  cases  have  been  reported,  however, 
in  which  this  was  the  case,  and  in  which  the  discharges  were  con- 
tagious. A  few  cases  have  also  been  reported,  in  which  the 
disease  produced  severe  attacks  of  peritonitis. 

352.  In  general,  but  slight  constitutional  symptoms  are  deve- 
loped, and  these  are  so  temporary  that  they  give  the  patient  but 
little  uneasiness.     In  other  cases,  however,  if  the  inflammation  be 
very  severe,  the   patient   will   suffer   from  rigors,   heaviness   and 
languor,  pain  in  the  back  and  round  the  loins,   headache    and 
thirst,  with  a  quick  pulse  and  a  loaded  tongue.     These  symptoms 
are  mitigated,  or  disappear  on  the  establishment  of  the  discharge. 

353.  The  question  arises   here — is    gonorrhea  a  purely  local 
affection  ?     From  the  experience  that  I  have  had  in  it,  I  think  it 
is  not,  and  in  this  opinion  I  am  supported  by  some  of  the  best 
authorities.     On  this  subject,  M.  Erichsen  says  :    "  Although  the 
gonorrhea  in  the  early  stages  is  doubtless  a  strictly  local  affection, 
yet,  there  is  a  particular  train  of  phenomena  occasionally  follow- 
ing it,  of  a  very  characteristic  nature,  that  can  scarcely  be  looked 
upon  in  any  other  light,  than  as  being  the  results  of  constitutional 
infection,  the   more  so,   as  they  are  very  apt  to  occur  in  some 
individuals,  who  never  have  gonorrhea  without  the  disease  being 
followed  by  these  consequences,  while  others  are  altogether  exempt 
from  them.     The  parts  that  are  principally  affected,  are  the  fibrous 
tissues,  the  mucous  and  the   cutaneous  surfaces.     The  affections 
of  the  fibrous   tissues  give  rise  to  rheumatism,  and  to  peculiar 


182  DISEASES     OF    WOMEN. 

forms  of  disease  of  the  testicle  and  of  the  sclerotic.  Th&  affection 
of  the  mucous  membrane  displays  itself  in  specific  inflammations 
of  the  throat  and  of  the  eyes,  and  the  skin  becomes  the  seat  of 
certain  eruptions.  The  occurrence  of  these  various  affections, 
assuming  as  they  do,  a  specific  type  so  distinctly  marked,  that 
they  can  at  once  be  characterized  as  gonorrhea!,  certainly  tends  to 
show  that  the  disease  impresses  the  constitution  in  some  peculiar 
manner,  something  analagous  to,  though  in  a  far  minor  degree, 
and  with  much  less  certainty  than  syphilis." 

354.  Affections  of  the  fibrous  tissues,  following  gonorrhea,  in 
the  female  are  rare ;  the  affections  of  the  skin  and  mucous  mem- 
brane are,  so  far  as  my  experience  extends,  far  more  common  in 
the  female  than,  in  the  male.     These  attacks  generally  occur,  in 
from   six   weeks   to   three   months,   after  the   first  attack.      The 
cutaneous  eruption  that  I  have  noticed,  consisted  of  a  superficial 
inflammation  of  the  skin,  which  appeared  in  patches,  and  gave 
the   patient  much  uneasiness,  on   account  of  the  itching   which 
accompanied  it ;  these  patches  appear  principally  over  the  abdo- 
men and  chest ;  as  soon  as  their  color  begins  to  fade,  the  epithe- 
lium is  partially  thrown  off  in  fine  scales  :  it  presents  no  sign  of 
the  coppery  redness  accompanying  syphilitic  skin  diseases.     The 
throat  commonly  becomes   similarly  involved  at  the  same  time, 
presenting  a  superficial  redness  on  the  pillars  of  the  fauces,  and 
the  velum-palatti,  with  sometimes  superficial  ulceration  on  these, 
the  tonsils  and  the  uvula.     The  occurrence  of  these  affections  is 
usually  preceded  by  slight  febrile  action,  which,  however,  subsides 
on  their  full  evolution.     These  secondary  affections  never  occur 
only  in  those  cases  in  which  the  primary  local  disease  has  not 
been  properly  treated. 

355.  Diagnosis. — Can  gonorrhea  be  diagnosed  from  other  inflam- 
matory diseases  of  these  parts  ?     According  to  Dr.  Churchill,  the 
distinction   between    vaginitis    and    gonorrhea   is   very    difficult. 
The   discharge   from   the   urethra,   (though   it   does    occasionally 
occur,)   is  much  less   frequent  in  leucorrhea  than  in  gonorrhea. 
Out  of  every  two  hundred  cases  of  the  latter  kind,  Ricord  states 
that  eight  in  every  twelve  had  the   urethra   so   affected.      The 
glands  of  the  groin  are  also  much  less  frequently  enlarged  in 


GONORRHEA.  183 

simple  acute  vaginitis.  In  addition,  the  moral  character  of  the 
patients  will  afford  a  certain  amount  of  assistance  in  forming  a 
decision. 

356.  The   observations    of  Donne,   if   they  are   borne   out   by 
future    investigations,   will    furnish   the  most    reliable    means    of 
diagnosis.     He  states,  that  in  the  gonorrhea!  discharge  there  are 
certain   animalculre,  which  may  be  detected  by   the  microscope 
and   which   are   never   found   in   any   other   discharges   from   th 
vagina.     These  animalcules  may  be  recognized  by  the  elongated 
filiform   appendix  attached   to  their    bodies,  and   which  may  be 
seen  in  motion  if  the  discharge  is  recent. 

357.  As  the  diagnosis  of  this  affection  is  so  difficult,  the  phy- 
sician should  be  careful  not  to  express  an  opinion  in  these  cases. 
Even  if  he  is  satisfied  in  regard  to  the  cause,  it  is  seldom  that  any 
good  will  result  by  insisting,  even  with  the  patients  themselves, 
in  tracing  it  to  a  criminal  origin ;  while  on  the  other  hand  the 
knowledge    that   the   discharge   in   simple    leucorrhea,  sometimes 
becomes  so  virulent  in  character,  as  to  produce  all  the  symptoms 
of  gonorrhea  in  the  male,  should  make  him  extremely  careful,  lest 
he  wrongfully  accuse  an  innocent  person. 

358.  Treatment. — In  the  ordinary  cases  of  gonorrhoea  in  women, 
the  treatment  is  quite  easy  if  they  are  so  situated  that  the}'  can 
follow  directions.     Best  and  cleanliness  are  two  essential  elements. 
Best  means  the  recumbent   position  and  quiet  until   the  active 
inflammation   has  passed  off,  if  this  is  possible.     To  relieve  the 
inflammation   and   for   cleanliness,  we   order  a  warm   sitz-bath, 
(sometimes  a  cold  sitz-bath  is  more  grateful),  the  diseased  parts 
being  thoroughly  washed  with  glycerine  soap  whilst  taking  the 
bath.     This  bath  may  be  repeated  two,  three,  or  four  times  a  day, 
at  first,  and  when  there  is  no  further  occasion  for  the  buth,  a  large 
bowl  of  water  is  so  placed  that  the  patient  sitting  over  it  can  wash 
thoroughly.     Sometimes  a  weak  salt-water  is  less  irritant  than 
simple  water  ;  sometimes  it  is  a  weak  solution  of  Chlorate  of  Pot- 
ash, Borax,  or  Acetate  of  Lead.     If  the  upper  vagina  is  involved, 
an  injection  pipe  will  be  required. 

If  there  is  tenesmus,  we  order  an  Opium  suppository.     Moving 
the  bowels  every  second  day  with  a  saline  laxative — Prof.  Howe's 
Crab  Orchard  Salts  and  Sulphur  does  very  well,  with  a  small  por 
tion  of  Cubebs  after  the  first  week. 


184  DISEASES     OF     WOMEN. 

Put  the  patient  upon  the  use  of:  R  Tincture  Veratrum,  gtt.  xx.; 
Tincture  G-elseminum.  3ss.  to  3ij.;  Water,  giv.;  a  teaspoonful  every 
hour.  With  this  give  a  simple  diuretic  as  Althaa,  Hair  Cap  Moss, 
an  infusion  of  Melon  Seed,  until  the  urine  becomes  moderately 
free,  and  then  Acetate  of  Potash,  with  an  abundance  of  diluents 
to  maintain  the  action.  Usually  twenty-four  or  forty-eight  honrs 
of  this  treatment  gives  marked  relief,  and  we  now  add  Cannabis 
Indica,  Macrotj'S,  Pulsatilla  or  Staplij'sagria,  as  may  be  indicated. 

When  the  disease  is  confined  to  the  urethra,  I  would  risk  the 
abortive  treatment.  Nicely  round  the  pine  stick  to  the  size  of  a 
catheter,  the  end  being  made  very  smooth,  dip  it  in  the  Kitric 
Acid,  wipe  diy,  and  after  a  minute,  introduce  it  as  you  would  a 
catheter.  Of  course  it  burns,  though  the  burning  does  not  per- 
sist as  one  would  suppose,  and  is  soon  succeeded  by  a  feeling  of 
relief.  The  same  means  may  be  used  at  any  pai't  where  the  dis- 
ease is  localized  and  can  be  reached  in  this  way.  I  am  sure  it 
offers  the  only  certain  cure  for  gonorrhoea  of  the  cervical  canal. 

Following  these  sharp  applications,  the  patient  is  kept  quiet,  put 
upon  the  use  of  sedatives,  and  has  a  hot  sitz-bath,  or  an  Opium 
suppository  if  necessary. 

When  the  discharge  has  become  profuse,  I  have  obtained  more 
benefit  from  Macrotys,  Cannabis,  Staphysagria  and  Pulsatilla,  than 
other  remedies.  Sometimes  the  old  prescription  of  Copaiba,  is 
very  good,  but  very  offensive.  Cubebs  is  much  pleasanter,  and 
may  be  used  in  powder  when  we  want  a  stimulant  action. 

359.  For  a  wash  when  the  discharge  is  abundant  we  may  pre- 
scribe Chlorate  of  Potash,  Sulphate  of  Zinc,  Permanganate  of 
Potash,  Carbolic  Acid,  or  what  I  prefer  to  all,  a  solution  of  Sul- 
phate of  Hydrastia,  grs.  iv.  to  Water  3  j.  It  should  be  used  after 
the  parts  are  well  cleansed,  and  held  in  contact  with  them  for 
some  time.  In  some  cases  more  benefit  seems  to  come  from  keeping 
the  mucous  surfaces  apart  rather  than  from  the  medicine.  Apiece 
of  soft  cotton  cloth  or  lint,  of  proper  width,  folded  upon  itself, 
and  wetted  with  Mucilage  of  Elm,  medicated  with  Acetate  of  Lead 
and  Morphia,  carried  up  with  the  finger,  a  spatula  or  something  of 
this  kind,  will  be  found  to  give  very  great  relief.  I  have  also 
employed  the  remedies  named  in  this  way.  Or  in  place  of  this, 
we  may  use  our  remedies  in  the  form  of  suppositorj7-,  introducing 
them  into  the  vagina. 


GQ.NORRHEA.  185 

In  chronic  cases  where  the  mucous  membrane  is  thickened  and 
spongy,  I  use  a  local  application  of  Nitric  Acid,  a  strong  solution 
of  Permanganate  of  Potash,  Sulphate  of  Zinc  or  Carbolic  Acid, 
as  may  seem  best  adapted,  but  in  either  case  so  as  to  change  the 
condition  of  the  part  and  the  secretion. 

360.  Where    the    gonorrheal    inflammation    is   located    at   the 
vulva,  warm  fomentations  should  be  employed,  until  the  irritation 
is  subdued.     The  parts  should  likewise  be  well  washed,  at  least 
twice  a  day,  with  warm  water  and  Castile  soap,  to  remove  the 
tenacious  secretions  from  the  parts.     If  there  be  much  pruritis 
present,  the  lotion  of  Borax  and  Morphia  will  be  found  to  give 
much  relief.     In  some  cases  a  poultice,  of  equal  parts  of  Ulmus 
Fulva  and  Hydrastis  Canadensis,  will  be  found  to  answer  a  better 
purpose  than  the  fomentations.     In  old  cases,  where   condylomata 
have  been  developed,  they  may  be  removed  in  the  manner  here- 
tofore spoken  of.     (See  Warty  Tumors  of  the  Vulva.) 

361.  The  treatment  of  gonorrheal  vaginitis  will  be  precisely 
similar  to  that  recommended  for  acute  and  chronic  vaginitis.     In 
the  chronic  form  of  this  disease,  however,  there  are  sometimes 
small  vegetations    springing   from   the  vaginal  walls,  which  will 
have   to  be  removed   before   any  treatment    will    be    successful. 
This  may  generally  be  accomplished  by  clipping  them  off  with  a 
pair  of  scissors,  and  touching  their  base  with  the  stick  Nitrate  of 
Silver. 

362.  The   inflammation  of  the    canal  of   the   cervix   that   so 
frequently  exists,  and  that  is  so  rarely  reached  by  the  remedies 
used  for  this  disease,  is  probably  one  great  cause  of  the  intractable 
nature  of  gonorrhea  in  the  female.     On  this  subject  Mr.  Langston 
Parker  says,  "I  believe  that  gonorrheal  diseases  in  the  female  are 
very  rarely  completely  cured.     This,  in  most  cases,  arises  either 
from  neglect  on  the  part  of  the  patient,  or  the  want  of  a  proper 
Icnowledge   of    the    disease,    careful    examination    of    the    parts 
affected,  and  an  appropriate  topical  medication  on  the  part  of  the 
surgeon.     If  Mr.  Whitehead's  notion  be  correct,  that  the  canal  of 
the  cervix  is  the  first  part  affected,  and  the   vaginal  or  urethral 
mucous  surfaces  are  only  secondarily  diseased,  the  disease  is  not 
likely  to  be  cured  without  topical  applications  to  the  primary  seat 


186  DISEASES     OF     WOMEX. 

of  the  complaint.  In  all  cases,  then,  of  suspected  gonorrhea,  the 
cervix  uteri  should  be  carefully  examined  with  the  speculum,  as 
soon  as  the  acute  inflammation  has  been  subdued,  so  as  to  admit  of 
its  use.  If  the  os  uteri  be  dilated,  the  mucous  secretion  should 
be  removed  from  it,  by  fixing  a  lock  of  cotton  on  a  pair  of  long 
dressing-forceps,  so  as  to  bring  the  vaginal  injections  in  contact 
with  the  diseased  surface.  If  the  disease  does  not  yield  under 
this  treatment,  a  solution  of  Sulphate  of  Zinc  (gr.  x  to  xx  to  Sj  of 
Water),  or  the  Sesqui-Carbonate  of  Potassa  (gr.  xv  to  xx  to  5j  of 
Water),  or  the  Nitrate  of  Silver  (gr.  xx  to  5j  to  5j  of  Water), 
should  be  applied  to  the  cavity  of  the  cervix,  with  a  camel's  hair 
pencil,  and  repeated  as  often  as  may  be  necessary.  In  all 
respects,  gonorrheal  inflammation  should  be  treated  in  the  same 
manner  as  simple  inflammation  of  the  cervix.  (See  Inflammation 
of  the  Cervix  Uteri.) 

363.  Many    causes    contribute    to    render    the    treatment    of 
gonorrhea  in  the  female  tedious  and  unsatisfactory,  and  a  disease 
more  difficult  to  cure  in  this  sex  than  in  the  male.    The  recurrence 
of  the  menstrual  period  is  constantly  interfering  with  the  success 
of  treatment,  and  a  gonorrhea  that  has  been  almost  subdued  in  the 
interval,  is  renewed  with  all  its  intensity  at  the  time  of  menstrua- 
tion.    Still,  if  the  course  that  I  have  recommended  be  judiciously 
pursued,  the  disease  may  be  entirely  eradicated.     The  disease,  if 
seen  in  the  acute  stage,  may  be  quickly  removed ;    the  chronic 
inflammation  of  the   parts   being  the   condition   where  the  most 
difficulty  will  be  experienced. 

SYPHILIS. 

364.  Syphilis  in  the  female  differs  but  little  from  the  same 
disease  in  the  male,  so  far  as  the  primary  disease  is  concerned ; 
there  is,  however,  a  marked  difference  in  the    sequences  of  the 
disease,  so  far  as  the  genital    organs    are    concerned,   and    this 
difference,  it  appears  to  me,  is  sufficient  to  call  for  a  description 
of  the  disease  in  a  work  of  this  kind.     The  differences  that  we 
have    to    notice  in  the    primary  disease,   consist  entirely  in  the 
anatomical    differences   in   the    structures    involved;    while   the 


SYPHILIS.  187 

secondary  effects  differ  not  only  as  regards  the  structure,  but  also 
as  regards  the  functions  of  the  entire  uterine  system. 

36G.  By  syphilis,  we  understand  a  specific  disease,  arising  from 
sexual  intercourse,  and  transmissahle  by  the  contact  of  its  own 
specific  pus  with  a  tender  surface,  by  inoculation  into  the  system 
through  the  medium  of  the  secretions,  or  by  hereditary  taint, 
under  certain  special  conditions.  It  has  been  supposed  by  some 
authors,  that  syphilis  and  gonorrhea  arise  from  one  and  the  same 
poison,  the  difference  in  the  two  being  merely  a  difference  in  the 
intensity  of  the  disease.  This  opinion  was  based  upon  the  fact, 
that  females  suffering  from  venereal  disease  would  communicate 
gonorrhea  to  one  person  and  syphilis  to  another,  both  having 
connection  with  one  woman,  and  at  short  intervals  from  each 
other.  Ricord  has  fully  proved  this  opinion  to  be  erroneous ;  he 
has  established  beyond  cavil,  that  the  gonorrhea!  discharge,  when 
inoculated  on  the  skin  or  mucous  membrane,  never,  under  any 
circumstances,  produces  a  chancre  ;  and,  conversely,  that  the  pus 
of  chancre  can  never  be  made  to  give  rise  to  gonorrhea.  He  has, 
however,  given  an  explanation  of  the  fact  upon  which  the  above 
opinion  was  founded  ;  it  is  now  well  known  that  a  woman  may  be 
affected  with  gonorrhea  and  deep  seated  chancre  on  the  uterus  at  the 
same  time,  so  that,  although  supposed  to  be  laboring  under  one,  she 
might  easily  communicate  both  or  either  of  the  diseases ;  the  true 
nature  of  her  disease  being  only  ascertainable  by  the  speculum. 

366.  Ricord  divides  syphilis  into  three  distinct  stages.  The 
first  stage  includes  primary  symptoms,  which  are  the  immediate 
effect  of  the  morbific  cause,  occurring  on  the  spot  where  the  virulent 
agent  has  been  deposited ;  as,  for  example,  chancres.  The  second 
stage  comprehends  secondary  symptoms,  which  are  the  sequence 
of  absorption  into  the  system  of  the  virulent  cause.  They  are 
hereditary,  but  not  capable  of  transmission  by  inoculation.  For 
an  example,  certain  affections  of  the  skin  and  mucous  membrane, 
iritis,  etc.  The  third  stage  comprises  tertiary  symptoms,  not 
capable  of  being  transmitted  by  inoculation,  nor  hereditary,  but 
subject  to  pathological  transformations  and  alterations  of  the  sub- 
mucous  and  sub-cutaneous,  or  of  the  fibrous  or  osseous  tissues. 

Primary  syphilis,  or  chancre,  may  be  developed  upon  any  part 


188  DISEASES     OF     WOMEN. 

of  the  female  organs  of  generation.  Its  most  common  location, 
however,  is  in  the  external  parts,  as  the  labia  majora,  the  nymplme, 
the  folds  of  mucous  membrane  surrounding  the  clitoris,  at  the 
orifice  or  other  parts  of  the  vagina,  or  at  the  meatus  urinarius. 
Chancres  yielding  a  characteristic  pustule  by  inoculation,  are  of 
very  rare  occurrence  on  the  cervix  uteri,  though  they  have  been 
met  with  in  this  situation,  and  even  at  the  os  uteri,  and  extending 
into  the  cavity  of  the  cervix.  They  have  likewise  been  met  with 
just  within  the  orifice  of  the  urethra,  on  the  rnons  veneris,  on  the 
perineum,  the  verge  of  the  anus,  and  within  the  sphincter  ani. 

367.  According  to  M.  Erichsen,  "  when  chancres  are  caught 
in  connection,  they  usually  commence  with  a   small  excoriation, 
which  appears  to  have  been  directly  inoculated  with  the  specific 
poison.     In  other  cases,  again,  though  more  rarely,  they  may  be 
seen   at  first  in    the    shape   of  a   small    pointed    pustule,   which 
speedily  breaks,  leaving  an  ulcer  of  a  specific   character  in  its 
site.     Very  generally,  however,  this  pustule  escapes  observation, 
and  the   disease   is  presented  in  the   first  instance  as  an  ulcer. 
The  chancrous  ulcer,  whatever  form  it  assumes,  seldom  makes  its 
appearance  until  a  few  days — five  or  six — after  connection.     In 
some  cases,  however,  I  have  observed  it,  evidently  from  the  infec- 
tion of  a  fissure  or  crack,  on  the  day  following  impure  intercourse, 
and,  occasionally,  in  rare  instances,  it  does  not  occur  until  a  much 
later  period  than  that  which  has  been  mentioned. 

368.  "Whatever  may  be  the  appearances  presented  by  a  chancre, 
there  can  no  longer  be  any  doubt  that  the  disease  arises  from  one 
kind  of  virus  only,  the  modifications  in  the  sore  depending  on  its 
situation,  the  constitution  of  the  patient,  and  occasionally  on  that 
of  the  individual  who  communicates  the  infection.    That  this  is  so, 
is  evident  from  the  fact  that  any  chancre,  when  inoculated,  reverts 
to  one  typical  form,  and  that,  however  much  chancres  may  ulti- 
mately differ,  they  all  present  the  same  characters  during   their 
•early  stages.     The  progress  of  a  chancre  that  has  been  artificially 
inoculated  on  any  part  of  the  cutaneous  surface  is  as  follows,  and 
its  study  will  serve  to  elucidate  what  takes  place  under  other 
circumstances.     During  the  first  twenty-four  hours  after  the  intro- 
duction of  the  specific  pus  into  the  skin  on  the  point  of  a  lancet. 


Plate  I 


1 


SYPHILIS.  189 

we  find  that  some  inflammation  is  set  up  around  the  puncture, 
which  becomes  hot,  red,  and  itchy.  About  the  third  or  fourth 
day,  a  pointed  pustule  is  produced,  which  is  at  first  deep-set,  but 
becomes  on  the  following  day  more  superficial,  with  some  depres- 
sion in  the  center,  resembling  pretty  closely  a  small-pox  pustule ; 
on  close  examination  this  will  be  found  not  to  be  a  true  pustule, 
out  rather  a  mass  of  epithelial  scales  and  pus  not  included  in  a 
distinct  wall.  On  the  fifth  day  it  has  become  hard  at  the  ba'se, 
apparently  from  the  infiltration  of  plastic  matter,  and  on  the  sixth, 
it  has  usually  dried,  forming  a  small  round  scab,  and  leaving  an 
ulcer,  which  presents  the  typical  characters  of  a  true  chancre, 
being  circular  and  depressed,  with  a  foul  grayish  surface  that  can 
not  be  cleansed,  sharp  cut  edges,  a  hard  base,  and  an  angry  look- 
ing red  areola  around  it.  This  is  the  typical  chancre,  and  these 
are  the  appearances  that  every  true  syphilitic  sore  on  the  skin 
will  present,  about  the  fifth  or  sixth  day  after  inoculation ;  from 
this  time  it  may  diverge  more  or  less  completely  from  these  char- 
acters, but  will  yet,  if  inoculated  at  any  time  during  the  poisonous 
stage,  produce  an  ulcer  that  will  run  the  specific  course  up  to  the 
same  period,  after  which  it  may  in  its  turn  again  deviate  into  one 
or  other  of  the  special  forms  that  chancres  occasionally  assume. 
When  inoculated  on  a  mucous  surface,  chancres  do  not  so  early 
assume  an  indurated  character  around  their  base." 

369.  By  reference  to  plate  I.,  the  progress  of  an  inoculated 
chancre  may  be  seen  from  its  commencement  to  the  fully-formed 
chancre. 

Fig.  2,  shows  the  result  of  the  inoculation  two  hours  after  the 
matter  was  inserted  by  the  lancet ;  already  may  be  marked  a 
tumefaction  of  the  tissues,  and  in  the  center  is  seen  the  puncture 
made  by  the  lancet,  surrounded  by  a  reddish  areola  of  small 
extent,  almost  confining  to  the  projecting  parts. 

Fig.  3.  Drawing  six  hours  and  a  half  after  inoculation.  The 
inoculation  is  still  more  elevated.  The  areola  is  of  a  deeper  color. 

Fig.  4.  Drawing  twenty-four  hours  after  inoculation.  The 
projecting  parts  appear  clearly  defined,  and  their  base  is  of  a 
deep-red  hue.  On  the  summit  is  seen  a  grayish  point,  corres- 


190  DISEASES     OF     WOMEX. 

ponding  to  the  incision  of  the  lancet.  The  inflammatory  areola 
has  comparatively  greatly  extended. 

Fig.  5.  Drawing  in  thirty-one  hours.  The  pustule  is  formed. 
The  grayish  point  of  the  morning  has  become  completely  black, 
nd  forms  a  small  gangrenous  eschar,  around  which  the  epidermis 
is  elevated  by  the  pus. 

Fig.  6.  Drawing  forty-eight  hours  after  inoculation.  All  the 
elements  of  the  pustule  are  progressing. 

Fig.  7.  Drawing  three  days  after  inoculation.  General 
progress.  We  remark  an  irregularity  in  the  periphery  of  the 
pustule,  which  during  the  night  discharged  some  pus,  and  in  the 
center  of  which  the  gangrenous  eschar  is  depressed,  and  appears 
to  be  adherent  to  the  subjacent  parts. 

Fig.  8.  Drawing  four  days  after  inoculation.  General  pro- 
gress. The  pustule  is  lacerated  at  several  points,  and  appears  to 
be  free  from  pus. 

Fig.  9.  Drawing  five  days  after  inoculation.  General  progress 
with  the  exception  of  the  inflammatory  areola,  which  appears  less 
intense.  The  irregular  eschar,  covering  the  wound  made  by 
inoculation,  was  removed,  and  beneath  it  is  seen  a  roseate  base 
studded  with  yellow  spots.  On  the  edges  which  are  scarcely 
separated,  is  seen  a  whitish  border  formed  by  the  epidermis. 

We  may  distinguish  three  varieties  of  chancres: 

370.  First,  The  simple  chancre,  characterized  by  the  absence  of 
induration,  and  but  a  low  degree  of  irritability,  or  inflammation. 
It  consists  of  an  excoriation  of  shallow  character,  with  sharp  cut 
edges,  and    somewhat    circular  in   shape,  and    having   a   tawny- 
grayish,    or    yellowish    surface,    surrounded    with    a   narrow    red 
areola ;  it  is  in  many  cases  attended  with  much  heat  and  itching. 
This  is  the  variety  of  chancre  most  generally  found  on  the  female 
genitals. 

371.  Second,  The  indurated  or  true  Hunterian  chancre ;  this 
is  very  rarely  met  with.     It  is  characterized  by  the  induration  of 
its  edges  and  base,  its  circular  shape,  its   elevation  above   the 
surrounding  parts,  and  the  very  adherent  gray  slough  that  covers 
its  surface. 


SYPHILIS.  191 

372.  Third,    The    sloughing    or  phagedenic    chancre;    this    is 
characterized  by  its  more  or  less  rapid  destruction  of  the  tissues 
of  the  parts.      One  variety  of  this  is  not  covered  by  a  slough ;   it 
spreads  rapidly,  has  sharp  cut  edges,  and  is  attended  with  some 
inflammatory  action.     The  other  variety  is   covered  by  a  slough, 
either  white,  gray,  or  black  ;  it  lias  the  same  tendency  to  erosion, 
though  in  general  it  does  not  progress  so  fast.      Chancres  of  the 
vulva   or  vagina  are  easily  detected  ;  those,  however,  which  arise 
on  the  os  uteri  may  exist  for  a  great  length  of  time,  sometimes, 
in  fact,  until  secondary  symptoms  are   observed,  before  there  are 
sufficient    local    symptoms    manifest    to    justify    an    examination. 
Ricord   states   that   non-indurated   chancres   of   the   neck  of   the 
uterus  are   often   painful,   especially  on  pressure,  and   in   sexual 
intercourse.     They  cause  a  sensation  of  weight  at  the  fundament, 
and  pain  in  the  lumbar  and  hypogastric  region.     Like  chancres  in 
other  places,  they  have  a  greater  tendency  to  extend   and   assume 
a  phagedenic  form.     The  suppuration  to  which  they  give  rise  is 
abundant,  may  stimulate  a  vaginal  discharge,  and  give  rise  to  a 
suspicion  of  blennorrhagia,  and  subsequently  to  the  transmission 
of  chancres  to  the  male,  by  a  woman  who  had  only  a  discharge. 
The  presence  of  these  symptoms  should  cause  the  physician  to 
make  a  rigid  examination  of  the  parts  with  the  speculum.     No 
matter  what  the  nature   of  the   disease  is,  the   symptoms   point 
directly  to  the  cervix  as  the  seat  of  it,  and  an  examination  should 
be  instituted,  or  the  patient  given  up  to   some   practitioner  Avho 
depends  more  upon  the  knowledge  of  the  agents  he  uses,  than 
upon  the  character  of  the  disease  for  which  he  uses  them.     In  my 
practice  I  never  take  no  for  an  answer.     I  must  know  exactly  tho 
nature  of  the  disease,  before  prescribing,  and  if,  from  motives  of 
delicacy,  this  is  denied,  I  advise  them  to  employ  some  one  else. 

373.  Upon  examination,  a  chancre  of  the  cervix  may  be  dis- 
tinguished from  any  other  ulceration,  by  its  circular  form,  by  its 
well-defined  edges,  by  the  red  areola  which  surrounds  it,  by  the 
grayish  slough  which  covers  it,  and  especially,  by  the  results  of 
inoculation.     There  have  been  doubts  raised,  however,  in  regard 
to  this  last  means  of  diagnosis,  some  ulcers  exactly  resembling 


192  DISEASES     OF     AYOMEN. 

chancres,  not  producing  the  characteristic    pustule;  but  the  evi- 
dence is  positive,  if  the  inoculation  succeeds. 

374.  Plate    I.,  Fig.  1,   presents  an  illustration  of  chancre  on 
the  posterior  lip  of  the  uterus.     It  has  assumed  a  slight  phage- 
lenic  character,  and  has  lost  its  circular  appearance.      On  the 
.eft  thigh    may  be   seen  the   characteristic  pustule  produced  by 
inoculation. 

375.  Syphilis  in  the  female  very  rarely  produces  enlargement 
of  the  inguinal  lymphatic  glands,  or  bubo,  without  the  chancre  is 
located  on  the  labia  majora,  and  even  then,  it  is  of  much  less 
frequent  occurrence  than  in  the  male. 

376.  The  length  of  time  that  elapses  between  impure  coition 
and  the  production  of  a  chancre,  or  between  the  formation  of  a 
chancre   and  the  development  of  one,   and  the  manifestation  of 
secondary  symptoms,  varies  much  in  different  individuals.     Thus, 
it  is  said,  that  the  period  between  exposure  and  the  production  of 
a  chancre,  in  some  few  cases,  has  been  as  long  as  three  or  even 
six  months,  and  in  some  of  these  cases,  the  primary  and  second- 
ary   symptoms    were    developed    simultaneously.       Again,    it   is 
stated,  that  the  constitution  may  be  affected  in  a  few  days  after 
the  development  of  the  pustule.     In  a  majority  of  cases,  how- 
ever, constitutional  infection  will  not  have  taken  place,  until  the 
chancre  has  been  fully  formed,  and  secreting  the  specific  virus  for 
several  days. 

377.  Secondary  Symptoms. — The  secondary  symptoms  will  be 
considered  here,  only  so  far  as  they  affect  the  uterine  organs  and 
the    function    of    reproduction.      Secondary   symptoms    may   be 
developed  as  the  result  of  an  imperfectly  cured  chancre  on  the 
external  parts,  or  from  the  absorption  of  the  virus  from  a  sore, 
before  any  treatment  was  adopted ;  or,  as  the  result  of  a  virulent 
chancre  on  the  cervix  uteri,  but  which,  on  account  of  the  low 
degree   of  sensibility  of   this  part,   did   not  manifest    sufficient 
symptoms  to  direct  the  attention  of  the  patient  to  the  disease  ;  or, 
when  the  mother,  being   in  health,  becomes  impregnated  by  a 
husband,  who  is  at  the  time  affected  by  secondary  syphilis,  and 
receives  the  secondary  disorder  through  the  medium  of  the  ovum. 
M.  Ricord,  the  greatest  modern  authority  in  syphilis,  believes  that 


w 


Plate H 


SYPHILIS.  193 

when  the  primary  poison  is  taken,  it  remains  for  several  days  in 
a  state  of  incubation,  during  which  time  the  poison  may  be 
destroyed,  without  any  danger  of  the  subsequent  occurrence  of 
constitutional  disease  ;  that  after  this  time,  chancres  take  certain 
characters,  and  infect  the  whole  constitution,  giving  rise  to  a  train 
of  evils,  known  as  constitutional  syphilis.  He  does  not  believe 
that  a  sore  or  chancre,  capable  of  communicating  syphilis  by 
inoculation,  can  ever  appear  as  a  secondary  symptom.  He  is  of 
an  opinion,  that  for  the  presence  of  constitutional  symptoms,  it  is 
absolutely  necessary  that  a  primary  sore  should  have  preexisted, 
except  under  the  conditions,  namely  :  that  a  man  suffering  from 
constitutional  syphilis,  may  impregnate  a  healthy  woman,  and 
the  germ  may,  in  the  first  place,  have  constitutional  syphilis ;  and 
in  the  second,  communicate  it  to  the  mother,  without  the  exist- 
ence of  any  primary  disease  in  either  mother  or  child.  He  does 
not  believe  in  the  communication  of  syphilis  in  the  secretions,  or 
by  the  discharges  from  secondary  eruptions  and  sores.  Nor  does 
he  believe,  that  a  child  affected  with  secondary  syphilis,  can  com- 
municate the  disease  to  a  healthy  nurse  ;  or,  that  a  nurse  affected 
with  constitutional  syphilis,  can  convey  the  disease  to  a  healthy 
infant,  through  the  medium  of  the  milk. 

The  following  are  the  propositions  laid  down  by  M.  Ricord : 

1st.  The  father  and  mother  may  transmit  the  disease  to  their 
child  indifferently,  if  either  or  both  of  them  be  affected. 

2d.  Transmission  may  occur  from  the  parents  to  the  child, 
when  they  are  affected  with  constitutional  symptoms,  or  when  a 
concealed  syphilitic  diathesis  exists  in  them. 

3d.  The  absence  or  existence  of  constitutional  symptoms  in 
parents  at  the  moment  of  impregnation  and  conception,  exerts  no 
influence  on  the  form  the  disease,  which  may  afterward  appear  in 
the  child.  The  distinction  established  by  M.  Cazenave  between 
congenital  and  hereditary  syphilis,  and  which  is  based  on  the 
absence  of  constitutional  symptoms  in  the  parents  at  the  moment 
of  generation,  or  which  have  been  developed  in  the  mother  during 

13 


194  DISEASES     OF     WOMEN. 

gestation,  is  totally  erroneous  ;  and  indeed  M.  Cazenave  confesses 
that  his  opportunities  of  observing  have  not  been  ample. 

4th.  The  character  and  period  of  the  manifestation  of  the 
symptoms  in  the  child  are  governed  by  the  stage  to  which  the 
disease  had  advanced  in  the  parents,  at  the  moment  of  generation. 
The  treatment  to  which  the  parents  were  subjected  may  also 
retard,  prevent,  or  modify  the  appearances  of  the  child. 

5th.  If  the  parents  are  both  healthy  at  the  time  of  generation, 
and  the  mother  contracts  syphilis  during  gestation,  she  may 
transmit  the  disease  to  her  child.  Of  this  I  have  seen  several 
examples  at  various  periods  of  pregnancy,  even  to  the  seventh 
month  inclusive. 

6th.  When  the  venereal  poison  is  transmitted  from  the  mother 
to  the  child  during  pregnancy,  infection  takes  place  through  the 
medium  of  the  placenta,  and  in  this  case,  appears  to  occur  after 
the  fourth  month  of  utero-gestation. 

If  the  father  alone  be  diseased  at  the  moment  of  generation, 
an  abortion  may  occur  at  any  period  of  pregnancy.  If  the  mother 
alone  be  diseased  at  the  time  of  conception,  the  abortion  will  not 
take  place  until  after  the  fourth  month. 

7th.  Children  born  of  a  father  or  mother  affected  with  syphilis 
may  escape  infection ;  for  a  certain  disposition  to  receive  constitu- 
tional disease  is  necessary  for  the  child  as  well  as  the  adult,  and 
this  may  be  absent. 

8th.  Observations  made  as  accurately  as  possible  seem  to  prove 
that  constitutional  syphilis  may  be  transmitted  from  the  child  to 
the  mother  during  utero-gestation. 

378.  Dr.  Tyler  Smith  says,  "  In  the  cases  of  supposed  trans- 
mission of  secondary  syphilis  between  man  and  woman,  there 
almost  always  must  be  the  doubt  of  a  new  inoculation  by  primary 
matter.  Indeed,  the  doubt  must  be  constant,  unless  we  could 
place  implicit  reliance  on  the  truth  of  all  the  parties  concerned, 
and  this,  in  such  cases,  must  seldom  be  possible. 

"  In  private  practice  in  this  country,  the  most  common  mode  in 
which  syphilitic  leucorrhea  of  a  secondary  character  occurs,  is, 
where  the  husband  has  had  syphilis  before  marriage,  and  is  liable 


SYPHILIS.  195 

• 

to  occasional  outbreaks  of  secondary  or  tertiary  disorders.  In 
such  cases,  the  ill-health  of  the  wife  dates  from  the  first  three  or  four 
months  of  pregnancy.  Sometimes  she  has  other  secondary  mani- 
festations, such  as  alopecia,  sore-throat,  and  cutaneous  eruptions. 
In  others,  leucorrhea  is  the  chief  noticeable  symptom.  We  know 
that  in  such  cases,  the  ovum  is  frequently  diseased,  the  membranes 
are  unhealthy,  or  the  foetus  is  affected  with  secondary  syphilis,  or 
specific  eruptions  break  out  within  a  few  weeks  after  birth.  We 
can  not  wonder  that  in  such  cases  the  mother  becomes  diseased  ; 
for,  by  means  of  the  foetal  circulation,  the  blood  of  the  male 
parent  is  brought  almost  as  directly  into  contact  with  the  female, 
as  though  a  tube  was  placed  between  the  vessels  of  the  parties, 
and  the  circulating  fluid  allowed  to  interfuse.  Generally,  both 
mother  and  child  are  affected  ;  more  rarely,  the  mother  is  affected 
and  the  child  remains  healthy ;  and  cases  occasionally  occur  in 
which  a  mother  bears  a  family  of  children  by  a  husband  suffering 

•j  is  O 

from  secondary  disorder,  all  of  whom  are  unmistakably  diseased, 
while  she  escapes  apparently  with  perfect  impunity.  I  believe  I 
have  seen  cases  in  which  syphilis  has  caused  the  death  of  the 
mother,  or  permanent  loss  of  health,  while  the  child  remained 
unaffected ;  and  I  am  sure  I  have  seen  cases  in  which  many 
children  have  been  destroyed,  the  mother  remaining  pure.  Women 
imbued  with  the  syphilitic  poison  frequently  bear  large  families ; 
but  I  have  seen  cases  in  which,  apparently  without  any  other 
cause  than  the  syphilitic  taint,  permanent  sterility  has  followed 
upon  the  pregnancy  which  occasioned  the  infection.  When  the 
mother  is  once  affected,  and  no  treatment  is.  resorted  to  by  the 
husband,  a  fresh  dose  of  the  secondary  poison  is  imparted  at  each 
pregnancy.  As  regards  the  length  of  time  after  an  attack  of 
primary  syphilis,  during  which  a  man  may  beget  a  diseased  ovum, 
it  is  difficult  to  give  a  positive  opinion.  It  is  more  a  matter 
-of  temperament  and  constitution  than  of  years.  Some  habits 
throw  off  the  syphilitic  poison  readily,  and,  to  all  appearances, 
completely;  others  retain  it  for  a  long  course  of  time.  It 
adheres,  <?ce£m's  paribus,  less  tenaciously  to  the  constitution  in 
youth,  than  when  the  disease  has  been  contracted  during  mature 
manhood. 


196  DISEASES     OF     WOMEN. 

» 

379.  "  The    appearances    presented    by    secondary    syphilitic 
leucorrhea   do   not  differ  materially   from   the   appearances    pre- 
sented in  other  severe  cases  of  leucorrhea.     It   is   this  circum- 
stance which  has  probably  led  to  its  doubtful  recognition  as  a 

orm  of  secondary  syphilitic  disorder.  Its  chief  characteristics 
are,  its  existence  in  connection  with  frequent  abortions,  and  with 
other  secondary  symptoms,  and  the  difficulty  experienced  in  its 
cure  except  by  anti-syphilitic  remedies.  In  secondary  leucorrhea, 
the  cervix  uteri  is  generally  soft,  swollen,  injected,  and  entirely 
denuded  of  epithelium.  It  hangs  loosely  in  the  vagina,  from  the 
weakening  of  the  vaginal  walls.  Eruptions  are  often  met  with  in 
the  upper  part  of  the  vagina,  and  upon  the  external  portion  of 
the  cervix.*  The  os  uteri  often  gapes  so  as  to  exhibit  the  rugae  of 
the  lower  part  of  the  cervix,  and  a  thin  yellow  purulent  matter, 
which,  when  mixed  with  morbid  secretions  from  the  cervical 
canal,  looks  something  like  honey,  or  honey  and  water,  exudes  in 
considerable  quantity  from  the  lower  part  of  the  uterus.  Occa- 
sionally, warty  growths  are  found  upon  the  os  uteri,  and  the 
vesicles  of  Naboth  are  sometimes  present  at  the  os  uteri.  The 
amount  of  discharge  in  such  cases  is  frequently  very  great." 

380.  Secondary  ulcerations,  the  result  of  constitutional  syphilis, 
may  also  be  developed  upon  the  cervix  uteri.     It  is  very  difficult, 
however,   if    not   impossible,   to   distinguish    between    these    and 
ulceration,  the  result  of  simple  inflammation.     There  is  no  doubt 
but  that   ulceration   of  the  cervix  uteri  is   much    more    common 
among  public  prostitutes  than  in  any  other   class.     Dr.  Bennet 
states,  that  while  be  was  in  charge  of  a  female  skin-ward  in  the 
Hospital,  St.  Louis,  there  was  always  a  great  number  of  syphilitic 
skin  diseases  ;  these  he  carefully  examined  with  the  speculum,  to 
ascertain  the   state   of   the   genital   organs.     The   result  of  this 
examination  was,  that  of  all  who  presented  symptoms  of  inflam- 
mation of  the  cervix,  he  found  the  cervix  ulcerated,  and  slightly 
indurated;  and   of  those  who   presented  no   such   symptoms,  he 
found  three  out  of  four,  "  perhaps  more,"  also  presented  ulcers 
on  the  cervix.     Most  of  these  patients  were  young  women,  who 
had  never  borne  children,  or  had  been    confined   several  years 
previously,    and    were    under    treatment   for  syphilitic   psoriasis, 

*  See  Figs.  3  and  4,  Plate  II. 


SYPHILIS. 

litclien,  rupia,  etc.  When  questioned  narrowly,  they  all  admitted 
that  they  experienced  slight  hypogastric  pain,  that  congress  had 
been  rather  painful  for  some  time  ;  and  some,  that  they  had,  like- 
wise, a  slight  leucorrheal  discharge.  They  had  not,  however, 
paid  any  attention  to  these  symptoms.  What  was  the  nature  of 
these  ulcerations  ?  Were  they  syphilitic,  modified  chancres,  or 
secondary  ulcerations,  or  were  they  merely  inflammatory  sores  ? 
In  their  appearance  I  could  discover  little  or  no  difference  from 
the  ulcerations  observed  in  non-syphilitic  patients,  and  was, 
therefore,  inclined  to  deny  their  general  syphilitic  nature.  Some 
were  large,  some  were  small;  some  had  a  well-defined  margin, 
others  not ;  sonic  were  covered  with  unhealthy  granulations, 
others  with  small,  florid,  healthy  granulations,  while  others  pre- 
sented a  membranous  film. 

381.  We  have,  then,  but  slight  ground  upon  which  to  form  a 
diagnosis  of  secondary  syphilitic  ulceration.     If  the  patient  pre- 
sent any  other  secondary  symptoms,  and  the  ulceration  is  some- 
what circular  in  form,  with  well-defined  edges,  and  has  a  coppery- 
red  areola,  with  or  without  small  coppery-red  granulations  on  a 
whitish  base,   scattered   over  the   surface   of  the  cervix,  we  will 
probably  be  justified  in  considering  it  the  result  of  secondary 
syphilis. 

382.  Syphilitic  vegetations  may  be  developed  upon  any  part 
of  the  genital  mucous  membrane,  though  they  are  generally  found 
upon  the   vulva,  or  the  orifice   of   the   vagina.      Some  of  these 
vegetations  resemble  wrarts ;  they  are  pale,  small,  and  arise  by  a 
base  which  is  generally   as  large  if  not  the  largest  portion   of 
the  growth.     Again,  there  is  another  variety,  which  arises  from  a 
larger  or  smaller  pedicle  ;  they  project  farther  from  the  mucous 
aiembrane,  and  are  of  a  deep-red  color ;  they  have  been  named 
the    strawberry  or    raspberry    excrescences.       (See    Figure    2, 
Plate  II.)     These   vegetations   often    give   rise  to  a  very  disa- 
agreeable  pruritus,  and  they  generally  give  rise  to   a  discharge, 
which  is  sometimes  of  a  very  offensive  odor.     There  is  no  doubt 
of  the  contagious  nature  of  these  vegetations,  not  that  they  will 
reproduce    either  primary  or  secondary  syphilis,  but    that    they 
themselves  are  capable  of  being  directly  transmitted.     Thus,  the 


198  DISEASES      OF      WOMEN. 

male  suffering  from  these  vegetations,  may  transmit  them  to  the 
female,  and  vice  versa. 

383.  Mucous  tubercles  is  another  form  of  syphilis  as  it  appears 
upon  the  genital  organs  and  other  parts. *  They  are  much  more 
frequently   seen  in   the   female  than    in    the    male,  owing  to  the 
extent  of  the  mucous  membrane  lining  the  genital  organs,  and  the 
delicacy  of  the  skin.     Though  generally  considered  a  consecutive 
accident,  yet  in  females,  it  is  said,  that  they  most  frequently  exist 
as   a  primary  symptom.      They  are    generally  found  about    the 
vulva  or  anus,  though  they  may  be  developed  in  any  other  portion 
of  the  body ;  they  may  appear  singly,  or  occur  in  groups ;  gen- 
erally where  there   is    one,   more   is    developed.      According    to 
Tidal,  when  seated  on  the  mucous  membranes,  the  color  is  more 
or  less  of  a  lively  red,  while   on  the  skin,  in  a  majority  of  cases, 
they  are  brown ;  around  them  the  coppery  areola  of  the  syphilitic 
eruptions  is  often  observed.     The  surface  is  sometimes  smooth, 
slightly  fungous,  and  sometimes  presents  a  macerated  appearance. 
Occasionally  they  are  completely    fungus,    and  of  a  violet  color. 
They  may  have  an  eroded  and  even  ulcerated  appearance,  resem- 
bling that  of  chancre;  especially  that  form  known  as  the  ulcus 
elevatum.     They  generally  secrete  a  serous-like,  or  sero-purulent 
fluid,  which  has  a  peculiar  and  repulsive  odor.     The  pus  becomes 
more  strongly  marked,  as  the  ulceration  is  established,  and  the 
pustules  are  irritated. 

384.  On   the  neck  of  the  uterus,  the  mucous  tubercle  is  often 
of  a  reddish-gray  color,  very  round,  distinct,  and  a  little   larger 
than  a  lentil.     It  has  been  seen  at  the  same  time,  on  both  sides 
of  the  upper  and  lower  lip. 

These  growths  may  appear  in  one  or  two  weeks  after  coition, 
or  some  time  after  the  development  of  a  chancre,  or  they  may 
appear  as  the  first  symptom  ;  they  are  then  primary.  M.  Ricord 
denies  the  contagiousness  of  mucous  tubercles ;  other  writers, 
among  whom  are  M.  Vidal,  M.  Waller,  and  Wallace,  have 
successfully  proved  their  transmissability. 

385.  Diagnosis. — In  many  cases  of  female  disease,  it  becomes 
if  the  greatest  importance  to  ascertain  exactly  whether  there  is 

*  See  Fig.  2,  Plate  II. 


STflliLiS.  199 

a  syphilitic  infection  of  the  system.  We  have  already  noticed 
the  principal  effects  of  this  protean  malady,  so  far  as  the  effects 
differ  in  the  two  sexes  ;  and  we  have  seen  not  only  the  health  of 
the  patient  affected  by  the  disease,  hut  also  her  offspring. 

386.  The  presence  of  syphilitic  disease  of  the  skin,  the 
exanthemata,  squama?,  vesicula?,  pustula?,  papula?,  tubercula,  etc., 
as  well  as  the  characteristic  secondary  symptoms  of  the  mucous 
membrane,  or  alopecia,  or  the  falling  off  of  the  hair,  will  be 
sufficient  evidence  to  cause  us  to  regard  either  structural  or 
functional  disease  of  the  uterine  organs  to  be  either  a  result  of 
secondary  syphilis,  or  to  be  greatly  aggravated  by  it.  On  this 
point  Mr.  Langston  Parker  says  :  "I  must  think,  with  Mr.  White- 
head,  that  the  greatest  majority  of  morbid  conditions  which  are 
found  on  the  lips  and  orifice  of  the  uterus,  in  females  who  are 
laboring  under  a  confirmed  venereal  taint,  are  of  syphilitic 
character  ;  probably  they  are  secondary,  or  rather  constitutional. 
It  is  rare  to  find  the  uterus  free  from  disease,  where  a  confirmed 
constitutional  taint  exists  ;  the  os  is  either  surrounded  by  a  ring 
of  inflammation,  or  the  lips  are  everted  and  red,  and  more  or  less 
thickened  ;  again,  superficial  ulcers  exist,  either  having  a  granular 
appearance,  or,  what  is  less  common,  the  edges  of  the  ulcer  well 
defined,  and  its  edges  elevated  and  hard."  M.  Gilbert  says,  we 
must  admit  that  this  granular  condition,  or  the  ulceration  of  the 
os  uteri,  is  due  to  syphilis,  and  belongs  most  commonly  to 
secondary  syphilis.  Again,  when  we  find  a  patient  habitually 
aborting  after  the  fourth  month,  the  probability  of  constitutional 
syphilis  should  cause  a  very  careful  examination  and  inquiry,  in 
regard  to  this  disease.  Syphilis,  at  this  day,  has  become  of  such 
common  occurrence,  especially  secondary  symptoms,  that  the 
probability  of  this  disease  being  present  should  always  be  borne 
in  mind.  The  character  of  the  patient  has  not  that  weight  here 
that  it  would  have,  were  constitutional  syphilis  always  and 
invariably  the  result  of  primary  disease  in  the  female.  But  we 
have  already  seen  that  a  female  may  become  infected  through  the 
ovum,  the  husband  having  constitutional  syphilis,  though  not 
aware  of  it,  and  thus  communicating  it  to  the  wife. 

If    abortion   habitually    occur   before    the    fourth    month,    th 


200  DISEASES     OF    WOMEN. 

condition  of  the  husband  should  be  ascertained,  if  possible, 
whether  he  has  had  syphilis,  the  time  that  has  elapsed  since  the 
primary  symptoms,  and  whether  secondary  symptoms  have  ever 
been  manifested. 

387.  These    inquiries    may   seem    out    of  place    to   those  Avho 
practice  medicine  in  the  country,  where  a  case  of  venereal  disease 
is  uncommon,  but  to   those  who   practice  in    large  cities,  their 
necessity  will  be  at  once  acknowledged.     It  is  a  humiliating  fact, 
but  one  that  is  true,  that  a  majority  of  young  men  who  have  been 
raised  in  the  city,  have,  at  some  period  of  their  lives,  been  affected 
with    syphilis.     This    may   have    been    eradicated,  but    still    the 
presence  of  secondary  syphilis  is  extremely  common,  as  the  con- 
sulting-rooms  of  our  physicians  will  show.      It  is  also  a  noted 
fact,    that    under   the    treatment    of    those    who    make    venereal 
disease  a  speciality,  the  disease  is  often  not  eradicated  from  the 
system,  the  treatment  merely  checking  the  present  symptoms,  but 
which  are  liable  to  recur  from  any  exposure  or  excess.     Under 
these    circumstances    he    marries,    when    the    disease,    although 
secondary,  may  be  transmitted  to  both  wife  and  children. 

388.  Treatment. — We  have  first  to  consider  the  treatment  of 
primary  syphilis  or  chancre.     And  here  the  question  arises,  can 
we  prevent  the  infection  of  the  system  by  destroying  the  original 
sore  ?  and  if  so,  during  what  length  of  time  may  the  abortive 
treatment    prove    successful?      In   many   cases,    no    doubt,   the 
destruction  of  the  syphilitic  sore  may  prove  entirely  effectual,  in 
removing  every  trace  of  the  specific  virus  from  the  system ;  but 
to   accomplish  this,  it  is  necessary  that  the  sore  be  destroyed 
before  the  proper  secreting  structure  of  the  chancre  is  formed,  in 
fact,  in  the  pustular  stage.     This,  even,  is  not  always  sufficient, 
for  the  syphilitic  pus  deposited  upon  a  mucous  membrane  may  be 
absorbed  without  producing  either  pustule  or  chancre,  as  we  see 
in  primary  bubo,  or  the  bubo  d'embles.     Sometimes,  however,  a 
chancre  may  be  fully  formed,  giving  rise  to  the  characteristic 
pustule    by   inoculation,    and   still,    through    some    constitutional 
peculiarity  of  the  patient,  the  virus  is  not  carried  into  the  system  ; 
while,  therefore,  it  is  good  treatment  to  adopt  the  abortive  plan  in 
the  first  stages  of  the  disease,  it  should  always  be  done  in  connec- 


SYPHILIS.  201 

tion  with  the  same  constitutional  treatment  that  we  would  adopt  if 
ice  were  satisfied  that  the  virus  had  (dread //  been  absorbed. 

889.  Though  the  abortive  treatment  will  often  prove  successful 
in  males,  it  can  seldom  be  resorted  to  in  females,  from  the  fact 
that  the  disease  produces  less  uneasiness  with  them,  not  being 
severe  enough  to  call  their  attention  to  the  seat  of  the  affection, 
and  because  the  female  genitals  being  much  more  liable  to  disease 
than  the  male,  the  mind  is  not  so  impressed  with  their  importance. 
Thus,  the  pustular  stage,  in  nearly  every  case,  is  passed,  and  the 
sore  presented  to  the  surgeon  is  a  fully-formed  chancre,  probably 
of  some  weeks'  duration.  In  some  cases,  however,  through 
accident,  and  in  others  who  have  had  chancres  before,  and  are, 
therefore,  watching  the  first  symptoms,  the  physician  may  be  able 
to  adopt  the  abortive  treatment  with  some  probability  of  success. 

This  treatment  consists  in  thoroughly  destroying  the  primary 
sore  with  caustic,  and  thus  converting  it  into  a  healthy  ulcer.  For 
this  purpose  I  use  the  Potassa  Fusa,  though  many  others  use  the 
Strong  Nitric  Acid,  the  Nitrate  of  Silver,  the  Tincture  of  Chloride 
of  Iron,  etc.  In  using  either  of  these  agents,  if  the  chancre  be  in 
the  pustular  stage,  it  should  be  opened,  and  the  contained  matter 
carefully  removed ;  then  apply  the  caustic  to  the  surface  of  the 
sore  sufficiently  to  entirely  disorganize  its  base.  If  the  Potassa 
Fusa  is  used,  its  application  for  a  few  seconds  will  be  sufficient, 
and  as  soon  as  the  cauterization  is  accomplished,  the  sore  should 
be  covered  with  Lint,  saturated  in  Vinegar  and  Water.  As  a 
general  rule,  cauterization,  to  prevent  constitutional  infection, 
should  be  resorted  to  before  the  fifth  day,  and  even  then  it  may 
prove  ineffectual. 

390.  In  very  many  cases,  a  good  Mayer's  ointment,  (made 
strictly  according  to  the  formula)  will  be  the  best  dressing  after 
cauterization.  It  is  sufficiently  tenacious  to  remain  where  placed, 
protects  the  part  thoroughly,  and  gives  the  necessary  stimulation, 
The  sore  heals  by  granulation,  and  the  part  needs  rest  and  pro- 
tection. In  some  cases  an  astringent  and  stimulant  application  is 
necessary,  and  then  we  think  of  the  old-fashioned  dressing  of 
Port  Wine  and  Tannin — R  Port  Wine,  ^vj.;  Tannic  Acid,  31].; 


202  DISEASES     OF     WOMEN. 

apply  with  lint.  I  should  use  this  application  when  the  part  was 
spongy  and  deep-colored.  A  solution  of  Permanganate  of  Potash 
will  also  be  found  a  good  dressing  in  some  of  these  cases  ;  and 
once  in  a  while  a  weak  solution  of  Carbolic  Acid. 

Sometimes  we  find  that  a  dry  dressing  answers  a  better  pur- 
pose :  most  usually  in  cases  where  there  is  a  free  and  somewhat 
ichorous  secretion.  If  the  part  is  tumid  and  pallid,  I  would  use 
Sub-nitrate  of  Bismuth  ;  if  pallid  but  spongy,  Oxide  of  Zinc. 
Dry  Calomel  has  been  very  highly  recommended  as  a  dressing  for 
some  chancres,  but  I  doubt  whether  it  possesses  any  advantages 
over  those  named.  Once  in  a  while  a  case  will  present  in  which 
the  chancre  is  spongy,  secretes  profusel}*,  and  is  very  irritable, 
when  Oxide  of  Lead  (powdered  white  lead)  will  serve  our  pur- 
pose best.  But  whatever  means  are  employed,  it  is  certainly  good 
treatment  to  destroy  the  secreting  surface  of  the  sore,  and  prevent 
the  further  absorption  of  the  virus;  if  by  this  means  the  chancre 
can  'be  more  readily  healed,  providing  that  by  this  means  the 
patient  and  practitioner  is  not  lulled  into  a  fancied  security,  and 
thereby  omit  the  use  of  proper  constitutional  measures. 

391.  In  the  female,  there  is  rarely  any  symptoms  to  contra- 
indicate  the  use  of  the  caustic ;  it  may  be,  therefore,  employed  in 
any  stage  of  the  simple  chancre.  Here,  I  still  prefer  the  caustic 
Potassa,  using  it  to  a  sufficient  extent  to  destroy  the  secreting 
surface  of  the  ulcer,  using  the  acidulated  water  afterward  to  pre- 
vent any  extension  of  the  cauterization,  and  then  applying  a 
poultice  of  Ulmus  Fulva,  until  the  slough  has  separated.  If  the 
ulcer  should  be  granulating  in  any  part  of  its  surface,  this  part 
should  be  shielded  from  the  action  of  the  caustic,  by  a  small 
pledget  of  cotton  saturated  in  vinegar  and  water.  This  cauteriza- 
tion changes  the  action  of  the  tissues,  and  we  have  left  a  simple 
ulcer. 

To  this  ulcer,  we  may  apply  the  Mild  Zinc  Ointment,  until 
cicatrization  is  complete.  Or,  we  may  use,  if  the  ulcer  does  not 
heal  with  this  application,  a  weak  solution  of  the  Sulphate  of  Zinc, 
Nitrate  of  Silver,  or  Alum,  or  what  will  be  found  preferable  in 
many  cases,  a  solution  of  Tannin  in  port  wine.  If  the  chancre 
assume  a  phagedenic  character,  the  patient  should  be  confined  to 
her  bed,  and  elm  poultices  employed,  until  the  inflammation  is 


SYPHILIS.  203 

removed,  when  the  Mayer's  Ointment,  or  some  of  the  other 
dressings  named,  should  be  applied.  When  there  is  not  much 
inflammation  or  irritability,  the  phagedna  may  be  sooner  stopped 
by  the  use  of  caustics;  the  one  that  is  most  highly  recommended, 
is  the  Strong  Nitric  Acid.  This  cauterization  should  be  deep,  and 
repeated  sufficiently  often  to  check  the  progress  of  the  gangrene. 
The  dressings  in  these  cases,  should  be  frequently  changed,  as 
the  discharge  is  often  very  copious.  In  addition  to  these  local 
measures,  the  patient  should  be  put  upon  the  use  of  the  vegetable 
tonics,  and  some  of  the  feruginous  preparations.  The  diet  should 
likewise  be  nutritious,  but  easily  digested. 

In  all  cases  of  primary  syphilis,  strict  attention  should  be  paid 
to  the  habits  of  the  patient,  as  much  rest  should  be  taken  as  pos- 
sible, and  all  exposure  avoided.  The  skin  should  be  kept  in  a 
healthy  condition,  by  the  use  of  the  bath,  and  if  dry  and  husky, 
by  the  administration  of  some  agent  that  will  determine  the  cir- 
culation to  the  surface. 

392.  Secondary  Syphilis. — Here,    our    dependence    is    placed 
almost  entirely  on  the  constitutional  treatment,  or  the  use  of  those 
remedies  which  remove  the  syphilitic  virus  from  the  system.     We 
come  now  to  consider  the  most  important  point  in  the  treatment 
of  syphilis,  the  agents  by  which  constitutional  infection  may  be 
prevented,  and  which  will  remove  the  syphilitic   virus  from  the 
system  after  it  has  been  absorbed,  and  produced  secondary  symp- 
toms.    Of  these  agents,  I  may  enumerate  the  Iodide  of  Potas- 
sium, the  Iodide  of  Iron,  the  Iodide  of  Ammonium,  Phytolacca, 
Corydalis,    Ampelopsis,    Rumex,    Kalmia,    Thuja,     Scrofularia, 
Alnus,  etc. 

393.  The  benefit  derived  from  the  first  of  these  agents,  the 
Iodide  of  Potassium,  is  so  marked,  that  it  is  used  by  all  schools 
of  medicine.     Under  its  administration  alone,  many  cases  of  con- 
stitutional syphilis  have  been  radically  cured.      Still,  there   are 
some  cases  in  which  it  will  fail.     Under  the  use  of   small  doses 
(from  gr.  ij  to  v,)  the  appetite  will  generally  be  increased,  nutri- 
tion active,  and  the  strength  reestablished;  these  doses,  however, 
do  not  prove  anti-syphilitic.     To  make  the  remedy  effectual,  it 
should  be  used  in  doses  from  gr.  x  to  5ss,  three  times  a  day. 


204  DISEASES      OF      WOMEN. 

394.  The  Iodide  of  Iron  has  similar  properties  to  the  agent 
above-named ;  it  is,  however,  better  suited  to  persons  of  a  feeble 
constitution,  as  it  acts  directly  upon  the  system  as  a  tonic  and 
restorative.     It  may  be  administered  with  the  agents   hereafter 
spoken  of,  or  in  pills,  according  to  the  following  formula : 

fy     Sulphate  of  Iron,  3ijss. 
Iodide  of  Potassium,  gx. 
Tragacanth,  gr.  xxv. 
Sugar  (powdered),  3jss. 

Make  one  hundred  pills,  from  one  to  ten  to  be  taken  in  the  day. 

395.  The   other  agents    named  may  be  truly  called  vegetable 
anti-syphilitics,  and  the  list  of  these  might  be  considerably  in- 
creased.    They  may  be  used  separately  or  in  combination.     The 
combination  of  these  agents  that  is  generally  employed  by  Eclec- 
tics, is  the  Compound  Syrup  of  Stillingia;  but  I  prefer  to  select 
my  remedies  according  to  the  case  in  hand.     Some  of  them  are 
much  better  given  in  weak  infusion,  but  in  large  quantity,  as  the 
Alnus,  Corydalis   and   Eumex.     But   others,  as   the   Phytolacca 
and  Thuja,  may  be  given  in   quite  small  doses,  with  most  excel- 
lent results. 

396.  "While  using   these   remedies,   it  is    essential    that  strict 
attention  should  be  paid  to  the  general  health  of  the  patient ;  the 
bowels  kept  regular,  and  the  kidneys  and  skin  stimulated  to  a  full 
performance  of  their  functions. 

With  the  removal  of  the  constitutional  infection,  by  the  use  of 
the  remedies  above-mentioned,  the  local  disease  of  the  genitals 
is  easily  treated.  But  without  this  is  accomplished,  local  appli- 
cations to  the  diseased  parts  are  of  but  little  use ;  for  even  if  the 
local  disease  was  subdued,  the  presence  of  the  syphilitic  poison  in 
the  system,  would  directly  reproduce  it.  Syphilitic  condolymata 
may  be  removed  from  the  genitals,  either  by  cauterization,  the 
ligature,  or  excision.  Very  often,  however,  when  the  syphilitic 
poison  has  been  entirely  eradicated  from  the  system  by  the  use 
of  constitutional  remedies,  these  vegetations  will  disappear  spon- 
taneously. M.  Vidal  strongly  recommends  the  following  method : 


SYPHILIS.  20-J 

H    Savine, 

Alum  Calc.  aa.  ojss. 

Reduce  to  a  fine  powder.  Wash  the  vegetations  twice  a  day  with 
red  wine,  and  cover  them  afterward  with  a  thick  layer  of  the 
powder.  In  the  course  of  three  or  four  days  the  vegetations 
become  feeble,  and  the  patient  may  begin  to  remove  them  with 
the  finger  nails.  After  each  separation  there  is  a  slight  bloody 
discharge,  which  may  be  arrested  by  the  vinous  lotion,  after 
which  the  powder  is  reapplied. 

397.  Mucous  tubercles,  like  the  vegetations  above  referred  to, 
will  often  disappear  under  the  use   of  proper  constitutional  treat- 
ment, if  strict  attention  to  cleanliness  be   observed.     Sometimes, 
however,  local  measures  become  necessary.     If  the  tubercles  are 
not   ulcerated   or  inflamed,   the   local    application   of  the   Liquor 
Sodse  Chlorinata  will  be  found  a  very  good  application ;  under  its 
use  the  tubercles  become  smaller,  and  rapidly  disappear.     If  there 
is  ulceration,  the    solution  should    be  diluted  until   but  a  slight 

o 

smarting  sensation  is  produced.  Or  a  plaster  of  the  inspissated 
juice  of  the  Phytolacca  Decandra  may  be  used  with  much  advan- 
tage. In  one  very  stubborn  case  of  this  kind,  where  the  tuber- 
cles were  ulcerated  and  gave  rise  to  a  profuse  fetid  secretion,  I 
used  the  Extract  of  the  Trifolium  Pratense  with  entire  success. 
It  removed  the  troublesome  itching  which  sometimes  accompanies 
the  disease,  in  three  or  four  hours,  and  its  continued  application 
for  ten  days  removed  every  trace  of  the  tubercles. 

The  chronic  inflammation,  erosion,  and  ulceration  of  the  cervix, 
which  so  often  accompanies  this  disease,  will  readily  yield  to  the 
treatment  recommended  for  simple  inflammation  and  ulceration  of 
the  cervix. 

398.  The  functional  uterine  diseases,  which  so  often    appear 
during    secondary    syphilis,    will,   in    a    majority    of    cases,    be 
removed,  when  the  cause  that  produced  them  is  eradicated. 

In  concluding  the  description  of  this  disease,  I  can  not  too 
strongly  impress  the  fact  on  the  mind  of  the  reader,  that  in  every 
case  of  uterine  disease  complicated  with  secondary  syphilis, 
whether  that  disease  be  structural  or  functional,  the  removal  of 


206  DISEASES     OF     WOMEX. 

the  syphilitic  poison  is  the  first  step  toward  a  permanent  cure  ; 
and  when  this  is  removed,  the  local  disease  will  yield  to  the  usual 
remedies  for  such  affections. 


CHAPTER    IX. 


DISEASES   OF  THE  UTERUS. 

399.  Diseases  affecting  the  uterus  are  divided  into  two  classes, 
Structural   and    Functional.      Structural    diseases    are    those    in 
which    the    deviations    from    healthy    action    are    indicated   by 
symptoms  during  life,  and  by  appearances  after  death,  which  are 
always  the  result  of  some,  and  often  of  very  conspicuous  struc- 
tural lesions ;  while  functional  diseases  are  dependent  on  devia- 
tion from  the  natural  or  healthy  action  of  any  part  of  the  uterine 
system,  indicated  by  symptoms  during  life,  which,  on  examination 
after  death,  are  found  to  be  unconnected  with  any  discoverable 
change  of  structure. 

400.  The  relative  frequency  of   these  two   classes  of  uterine 
disease  is  hard  to  determine.     Some  practitioners  look  upon  all 
diseases  of  the  uterine  system  as  diseases  of  debility,  and  adopt 
their  treatment  to  this  supposed  condition.     Others  consider  that 
all  these  diseases  arise  from,  or  consist  in,  a  local  congestion  and 
engorgement    of    blood,    and   that    they    are    to   be  relieved  by 
remedies  directed  to  its  removal.     A  third  theory  has  been  suc- 
cessfully advocated  by  Dr.  Bennet,  and  adopted  by  a  large  por- 
tion of  the  profession,  that  the  majority  of  uterine  diseases  are 
inflammatory  in  their  nature,  and  that  we   are  sure  to  find,  in 
nearly  every  case,  inflammation,  or  some  of  its  results,  as  ulcera- 
tions,  purulent  discharges,  etc.     This  theory  of  uterine  disease 
Dr.  Bennet  supports  by  a  report  cf  three  hundred  consecutive 
eases  of  uterine  disease,  occurring  in    hospital  practice,  in  two 
hundred  and  forty-six  of  which  decided  inflammatory  disease  of 
the  cervix  uteri  was  present.     Again,  we  have  other  practitioners 


OCCLUSION  OF  THE  OS  UTERI.         207 

believing  that  a  majority  of  these  diseases  arise  from  displace- 
ment of  the  uterus  ;  and  others,  that  they  are  essentially  nervous 
or  neuralgic  disorders.  Many  other  theories  in  regard  to  the 
nature  and  cause  of  uterine  diseases  have  been  brought  forward, 
and  have  found  advocates  at  different  times,  though  the  ones  just 
mentioned  are  the  principal. 

401.  These  views  are  all   partially  correct,  yet  neither  of  them 
is  sufficient  to  account  for  all  the  morbid  manifestations  of  these 
organs,  nor  for  a  majority  of  them,  if  we  except  the  theory  of 
Dr.  Bennet. 

To  successfully  study  these  diseases,  it  is  necessary  to  recollect 
that  the  general  principles  of  pathology  apply  to  disease  of  the 
uterus  the  same  that  they  do  to  any  other  organ  of  the  body,  and 
that  any  special  or  exclusive  theory,  that  will  not  apply  equally 
well  to  disease  of  other  parts,  must  be  fallacious. 

402.  As  functional  diseases  of  the  uterine  system  involve,  to  a 
greater  or  less  extent,  both  the  uterus  and  ovaries,  and  as  they  so 
frequently  rise  from,  or  are  aggravated  by,  structural  diseases  of 
these  organs,  their  consideration  will  be  deferred  until  the  organic 
diseases   of   the   uterus   and   ovaries   have   been  described.     The 
same  anatomical  arrangement  will  be  followed  here  that  I  have 
adopted  in  the  previous  part  of  the  work,  classifying  the  diseases, 
as  far  as  possible,  according  to  the  structure  affected. 

OCCLUSION  OF  THE  Os  UTERI. 

403.  This  may  be  either  congenital,  or  the  result  of  disease ; 
and  it  may  be  either  partial  or  complete.     Congenital  occlusion 
not  unfrequently   occurs   with   occlusion   of   the   vagina,   as   has 
been  heretofore  described,  though  it   may  be  present  when  the 
vagina  is  perfect.     In  either  case,  it  is  of  very  rare  occurrence. 

404.  The  symptoms  of  congenital  occlusion  depend  altogether 
upon  the  presence  of  a  menstrual  discharge.     Until  the  period  of 
puberty,  when  this  secretion  takes  place,  this  obstruction  gives  no 
sign  of  its  presence,  and  in  some  cases  reported,  it  had  continued 
up  to  the  age  of  forty  years,  without  producing   any  difficulty  ; 
though,  in  these  cases,  there  was   never  any  symptoms  of  men- 
struation.     As    soon,    however,    as    the    menstrual    secretion    is 


208  DISEASES     OF     WOMEN. 

established,  we  will  find  a  monthly  return  of  those  symptoms 
accompanying  menstruation ;  considerable  uneasiness  and  distress, 
weight  in  the  pelvis,  uterine  tenesmus,  aching  round  the  loins 
and  by  degrees  an  increasing  tumor  above  the  pelvis,  resembling 
*n  form  the  impregnated  uterus.  These  symptoms  will  partially 
disappear  in  a  few  days,  but  will  recur  at  each  menstrual  period 
with  increased  violence. 

405.  Acquired  occlusion  may  depend  upon  various  accidental 
causes.    Thus,  it  may  arise  from  severe  inflammation  of  the  cervix 
uteri,   from    mechanical    lacerations,    from    the   use    of    caustics, 
applied  to  the  cervix  or  its  canal,  and  as  the  sequelae  of  labor. 
The    symptoms    of   acquired    occlusion    are    the    same    as    above 
described. 

Some  cases  have  been  reported  in  which  occlusion  occurred 
during  pregnancy.  A  case  of  this  kind  is  reported  by  Prof. 
Bedford. 

406.  Diagnosis. — In  cases  where  there  is  considerable  accumu- 
lation, with  enlargement  of  the  uterus,  it  would  be  very  easy  to- 
make  a  mistake  in  the  diagnosis,  if  care  was  not  used  in  making  an 
examination.    In  congenital  occlusion,  the  absence  of  the  menstrual 
secretion,  with  the  monthly  recurrence  of  the  symptoms,  should 
lead  us  to  suspect  that  the  cause  of  the  difficulty  was  retention  of 
the  menstrual  blood.     Upon  making  an  examination,  if  the  vagina 
be  found  perfect,   the  careful   examination    of   the    os   with   the 
uterine  sound  will  reveal  that  the  exit  from  the  uterus  is  imper- 
vious.      If    the    occlusion    is    acquired,   some    difficulty    may   be 
experienced  in  determining  whether  the  suppression  of  the  menses 
is  not  due  to  pregnancy.     Yet  here  the  recurrence  of  the  symp- 
toms with  no  discharge,  will  be  sufficient  to  make  us  suspect  the 
difficulty. 

407.  Treatment. — In  order  to  open  the  occluded  os  or  cervical 
canal,  we  might  first  attempt  to  pass  up  an  ordinary  sound,  with  the 
view  of  breaking  down  the  obstructions,  if  possible,   as.  in  some 
cases,  the  occlusion  is  but  slight.     If  this  does  not  succeed,  the 
opening  may  be  made  with  the  trocar  or  bistoury.     We  may  use 
the  speculum  here  with  much  advantage,  bringing  the  cervix  fairly 
into  view ;  the  trocar  should  be  placed  as  near  as  possible  to  the 


CONGESTION     OF     THE     CERVIX     UTERI. 

situation  of  the  os  uteri,  and  a  perforation  made  by  pressing  it 
upward,  until  the  contents  escape.  The  canula  ought  to  be  left 
in  the  wound  after  the  trocar  is  withdrawn,  until  the  uterus  is 
emptied. 

When  the  fluid  has  been  entirely  discharged,  a  bandage  should 
be  applied  to  support  the  abdomen,  and  the  patient  placed  in  bed. 
The  vagina  should  be  syringed  out  two  or  three  times  a  day,  until 
the  collected  blood  has  all  drained  away,  when  an  elastic  bougie 
should  be  introduced  through  the  cervix,  and  kept  there,  in  order 
to  prevent  the  closure  of  the  uterine  orifice. 

CONGESTION  or  THE  CERVIX  UTERI. 

408.  Congestion  of  the  cervix  uteri  is  of  very  frequent  occur- 
rence ;  it  is,  indeed,  one  of  the  most  common  diseases  to  which 
women    are    subject.       During    the    normal    performance    of   the 
menstrual  function,  the  uterus  and  ovaries  receive  an  increased 
supply  of  blood,  and  there  is,  consequently,  slight  and  temporary 
congestion,  though  this  does  not  affect  the   cervix  to  so  great  an 
extent  as  the  body  of  the  uterus.     This  congestion  is,  however, 
removed  as  soon  as  secretion  is  fairly  established.     If  the  cervix 
uteri  is  examined  at  the  commencement  of  menstruation,  it  will  be 
found  to  be  more  voluminous,  and  of  a  deeper  color  ;  if  after  the 
secretion  is  fairly  established,  it  will  be  found  slightly  congested 
and  near  its  natural  size,  the  os  being  larger  and  more  open.     As 
soon  as  menstruation  ceases,  the  cervix  and  os  will  be  found  in 
their  normal  conditions. 

409.  When  this  normal  congestion  is  increased  from  any  cause, 
and  continues  through  the  menstrual  interval,  we  then  consider 
it  a  disease.     As  congestion  in  the  first  stage  of  inflammation,  it 
may  rapidly  assume  an  inflammatory  form,  though  in  very  many 
cases,  it  continues  for  months  a  simple  congestion. 

410.  Symptoms. — In  many  cases,  the  symptoms  are  so  slight 
that  the  patient  makes  no  complaint  for  some  time.     If,  however, 
it  continues,  each  return  of  the  menstrual  period  will  be  accom- 
panied with  greater  suffering ;  the  menstrual  function  itself  does 
not  remain  long  intact,  sometimes  becoming  too  profuse,  at  others 
scanty,  or  its  place  supplied  with  a  discharge  nearly  white ;  the 

•„  14 


210  DISEASES     OF     WOMEN. 

periodicity  of  the  discharge  may  also  be  affected.  Thus,  it  may 
appear  more  frequently,  or  be  retarded  in  its  appearance. 
Between  the  menstrual  periods  the  patient  complains  of  a  constant 
pain  in  the  small  of  her  back,  of  a  weight  and  dragging  down  in 
the  pelvis,  which  are  all  increased  by  standing,  walking,  or  any 
kind  of  exercise.  There  is  almost  always  a  constant  leucorrhea, 
the  discharge  varying  in  character,  from  a  thin  milk-white  mucus 
to  a  thick  and  tenacious  secretion.  As  the  disease  continues,  the 
patient  will  complain  of  lassitude  and  weakness,  loss  of  appetite, 
and  other  symptoms,  showing  an  impaired  state  of  the  general 
health.  The  symptoms  described  are  common  to  congestion  and 
inflammation ;  in  fact,  it  is  hard  to  distinguish  the  dividing  line 
between  the  two  conditions. 

411.  Upon  making  an  examination,  the  cervix  will  be   found 
enlarged,  either  in  its  whole  extent,  or  only  partially,  the  conges- 
tion being  principally  confined  to  one  of  the  lips  of  the  os.     It 
will  also  be  found  lower  down  in  the  pelvis,  the  increased  weight 
of  the  organ  causing  a  greater  or  less  prolapse.     Upon  touching 
the  cervix,  it  will  be  found  soft,  yet  elastic,  and  having  the  same 
smooth,  unctuous  surface  which  characterizes  it  in  health,  strongly 
contrasting    with    its    condition    when    inflamed,    when    it    feels 
indurated,  dry  and  harsh,  and  increased  in  temperature. 

412.  The  presence  of  congestion  of  the  cervix  exercises  an 
unfavorable  effect  on  all  other  uterine  diseases,  whether  functional 
or  structural,  always  aggravating  them  and  making  the  cure  much 
more  tedious. 

413.  Causes. — The  most  frequent  cause  of  this  affection  is  cold, 
especially  during,  or  immediately  after  menstruation,  excessive 
coitus,  the  use  of  irritating  injections,  frequent  abortions,  etc.     It 
may  also  be  caused  by  violent  mental  emotions  and  long-continued 
and  violent  physical  efforts ;  in  fact,  from  any  cause  producing 
unusual  determination  of  blood  to  the  uterus,  without  a  corres- 
ponding amount  of  secretion,  either  during  or  in  the  intervals  of 
menstruation. 

414.  Treatment. — As  has  been  remarked,  the  continued  recur- 
rence of  the  congestion  is  not  only  a  cause  of  present  unpleasant- 
ness, but  is  a  fruitful  source  of  structural  disease  of  the  cervix, 


INFLAMMATION    OF    THE    CERVIX.  211 

uterus  and  ovaries.  It  is  Avell,  therefore,  to  give  the  case  a  very 
thorough  examination,  to  determine  the  indications  for  remedies. 
I  would  suggest  the  study  of  Macrotys,  Caulophyllum,  Pulsatilla, 
Viburnum,  Hamamelis,  Senecio,  Apocynuin,  Pihus,  Apis,  Bella- 
donna, Carbo-veg..  Iron  and  Copper,  in  this  ease. 

415.  We  find  a  group  having  dysmenorrhoea  as  a  prominent 
symptom,  the  congestion  of  the  cervix  being  attended  with   diffi- 
cult, or  it  may  be  tardy  menstruation.     In    this   case  I    like  the 
action  of  Macrotys   and  Pulsatilla.  ,"s*.  of  each  (the  tincture)   to 
water  Jiv.;  a  teaspoonful   lour  times  a.  day  for  four  or  five  days 
before  the  menstrual  period,  and  until  the  How  is  well  established. 
When  there  is  severe  expulsive  pain,  and    especially  in  the  early 
months  of  pregnancy,  there  is  no  remedy  equal  to  the  Viburnum. 
It  may  be   given  alone,  or  alternated  with    either   of  the   others 
named,  if  indicated.     The  Hamamelis  (Pond's  Extract)  is   espe- 
cially indicated  when  the  pelvic  tissues  are  full,  feeble,  and  there 
is  general  venous  congestion.     In  the  majority  of  these  cases  the 
patient  will  also  suffer  from  hemorrhoids.     The  dose  will  be  one- 
fourth  or  one-third  of  a,  teaspoonful  four  times  a  day.     The  Apo- 
cynum    is  especially  indicated   by  the  oedema  of  the  feet  which 
characterizes   some    cases,   though    examination    will    sometimes 
show  a  similar  condition   of  the  vulva  and    other   tissues.     The 
Carbo-veg.  is  the  remedy  when  the  menstrual  flow  continues  long 

~  «/  £3 

(passive)  and  recurs  too  frequently.  Cuprum  is  the  blood-maker 
in  these  cases. 

416.  Mild  astringent  and  tonic  injections  sometimes  prove  use- 
ful.    If  there  is  much    leucorrhoeal    discharge,  injections  of  Sali- 
cylic Acid  and  Borax,  Chlorate  of  Potash,  and  Sulphate  of  Zinc, 
or  Alum,  may  be  used. 

Tonics  and  restoratives  will  sometimes  be  indicated,  and  in  all 
cases  a  good  diet,  with  rest,  physical  and  mental,  will  aid  much 
in  effecting  a  permanent  cure.  In  some  cases  coitus  must  be  pro- 
hibited for  some  time,  as  well  as  the  use  of  that  modern  cause  of 
uterine  disease — the  sewing  machine. 

INFLAMMATION  OF  THE  CERVIX. 

417.  Inflammation  of  the  cervix  uteri  has  been  investigated  of 
late  years  with  great  care,  and  at  this  time,  it  has  assumed  a  great 


212  DISEASES     OF     WOMEN. 

importance,  with  uterine  pathologists.  These  investigations  were 
stimulated  by  the  work  of  Dr.  Bennet,  on  Inflammation  of  the 
Uterus,  published  in  1845.  In  this  Avork,  he  advanced  the  theory, 
that  the  majority  of  uterine  diseases  were  either  essentially 
inflammatory,  or  that  they  arose  from,  or  were  kept  up  by  inflam- 
mation. In  his  classification  and  description  of  uterine  disease, 
inflammation  of  the  cervix  uteri  and  its  results,  hold  a  prominent 
place,  from  the  fact,  that  it  was  the  most  common  disease,  being 
met  with  in  five  out  of  every  six  cases  of  uterine  disease,  and 
from  the  serious  train  of  consequences  which  arose  from  it,  and 
which,  by  other  authors  and  practitioners,  had  been  considered 
as  the  result  of  other  affections.  Since  the  views  of  Dr.  Bennet 
have  been  made  known,  they  have  been  adopted  by  many  of  the 
most  successful  practitioners  in  all  parts  of  the  world,  yet,  there 
are  many,  who  having  the  same  opportunities  for  investigation  as 
Dr.  Bennet,  deny  that  this  disease  is  of  such  frequent  occurrence. 
There  is  no  difference,  however,  between  authors,  so  far  as  the 
description  of  the  disease  is  concerned,  the  main  difference  being 
as  to  its  frequency,  and  its  so-called  results,  ulceration,  erosion, 
etc. 

418.  So  far  as  my  experience  has  extended,  I  am  inclined  to 
adopt  the  views  of  Dr.  Bennet,  as  thus  far  I  have  found  them 
borne  out  by  the  results  of  practice.     I  would  especially  urge  my 
readers,  to   bear  in   mind  the  symptoms  of  this  affection,  when 
examining  cases  of  uterine  disease ;  as  it  will  often  be  found,  that 
what  seems  to  be  a  functional  affection,  upon  a  superficial  examina- 
tion, has  its  origin,  or  is  kept  up  by  inflammation  of  the  cervix. 

In  the  description  of  the  symptoms  and  consequences  of  this 
disease,  I  have  principally  depended  upon  -Dr.  Bennet's  minute 
treatise  on  this  subject. 

419.  Causes. — The  physiological  functions  of  the  uterus,  men- 
struation and  gestation,  by  the  changes  which  they  produce  in  the 
condition  of  the  organ,  make  it  more  liable  to  inflammatory  action, 
than  any  other  portion  of  the  system.     Thus,  during  the  period 
of  menstruation,  the  uterine  system  remains  in  a  state  of  physio- 
logical congestion,  and  at  this  time  it  has  a  high  degree  of  vitiliza- 
tion,  and  is  peculiarly  susceptible  to  all  causes  of  disease,  as  cold, 


INFLAMMATION  OF  THE  CERVIX.       213 

titmospherical  vicissitudes,  etc.  The  menstrual  secretion  is  liable 
to  be  prevented,  diminished,  increased,  or  suddenly  arrested,  by 
many  other  causes  than  those  named,  either  mental,  social  or 
pathological ;  and  whenever  this  is  the  case,  the  natural  uterine 
congestion  may  become  morbid,  and  thus  give  rise  to  inflamma- 
tion. These  causes  act  both  in  the  married  and  single  state,  yet, 
in  the  last,  the  disease  is  not  of  such  frequent  occurrence.  In 
the  married  state,  the  cervix  uteri  is  exposed  to  another  fruitful 
cause  of  inflammation,  even  when  conception  does  not  take  place. 
The  physiological  congestion  and  excitement  which  accompany 
intercourse,  may,  if  too  frequently  renewed,  give  rise  to  inflam- 
mation, and  the  same  results  may  be  occasioned  directly  by  phy- 
sical contusion  of  the  organ  itself.  Gestation  likewise  increases 
the  susceptibility  of  the  uterus  to  disease,  and  this  susceptibility 
appears  to  be  more  manifest  in  the  cervix  than  in  any  other 
portion  of  the  organ.  At  this  time,  the  structure  of  the  uterus 
undergoes  a  complete  transformation  ;  its  tissue,  which  before  was 
of  almost  a  cartilaginous  hardness,  now  assumes  the  characteristics 
of  muscular  structure ;  the  arteries  and  veins  previously  so  small 
as  to  be  with  difficulty  detected,  now  become  enlarged  to  an  enor- 
mous extent,  and  the  entire  organ  becomes  one  of  the  most, 
instead  of  one  of  the  least  vascular  in  the  human  economy. 
This  condition,  therefore,  constitutes  a  predisposing  cause  of 
inflammation,  not,  however,  during  pregnancy,  for  the  uterine 
system  appears  to  be  peculiarly  exempt  from  inflammation  at  this 
time,  but  from  the  fact,  that  in  the  involution  of  the  uterus,  the 
cervix  never  regains  its  former  condition ;  it  still  remains  volum- 
inous, looser  in  texture,  and  more  plentifully  supplied  with  blood, 
and  it  has,  therefore,  a  greater  susceptibility  to  disease. 

420.  Parturition  is  also  a  frequent  cause   of  inflammation  and 
ulceration  of  the  cervix,  as  it  is  frequently  followed  by  inflamma- 
tion  of  the  uterus  involving  the  cervix,   which  may  perpetuate 
itself  in  the  latter  region,  even  when  it  has  been  subdued  in  the 
body  of  the  organ,  or  it  may  occasion  inflammation  of  the  cervix 
alone,  other  parts  of  the  uterine  system  not  being  simultaneously 
affected. 

421.  In  addition  to  the  predisposing  causes  named,  inflamma- 


214  DISEASES    OF    WOMEN. 

tion  of  the  cervix  may  also  be  the  result  of  the  extension  of 
vaginitis,  blennorrhagic  or  non-blennorrhagic,  or,  it  may  occur 
like  all  other  phlegmasige,  without  being  traceable  to  any  par- 
ticular cause. 

422.  Symptoms. — When  the  mucous  membrane   which   covers 
the    cervix    is  inflamed,   it    ceases  to  present,  to  the  touch,  the 
unctuous  surface  which  characterizes  it  in  health.     If  the  inflam- 
mation extends  to  the  deep-seated  structures,  or  if  it  commences 
there,  the  cervix  is  more  or  less  indurated,  as  well  as  enlarged, 
from  the  interstitial  effusion  that  takes  place.     When  the  uterine 
neck  is  thus  increased  in  weight,  it  nearly  always  falls  more  or 
less  in  the   vaginal  cavity,  so  as  to  approximate  the  vulva.     In 
married  females  it  is  also  generally  retroverted,  owing  to  physical 
pressure  in  congress.     When  the  inflamed  cervix  is  brought  into 
view  by  the   speculum,  its  surface  is  found  to  offer  a  vivid,  red 
tinge,  instead  of  the  pale  rose-color  of  health.     It  may  present  a 
uniform  red  hue,  and  be  dotted  with  florid,  red  papulae,  or  with 
white  pustules,   consisting  of   mucous  glands,   hypertrophied  or 
distended  wTith  muco-pus ;    or,    it   may   offer    any  of  the  shades 
between   the  bright  red  of  arterial  blood,  and  the  livid  tinge  of 
venous  blood,  according  to  the  state  of  the  circulation.     On  the 
inflamed   surface  we  find  a  certain   amount  of  muco-pus,  which 
generally  requires  to  be  wriped  off  before  the  state  of  the  mucous 
membrane  can  be  clearly  ascertained.     Dr.  Bennet  attaches  great 
importance  to  the  presence  of  muco-pus  as  an  evidence  of  inflam- 
mation, for  both  redness  and  tumefaction  of  the  cervix  may  be 
produced  by  mere    congestion,    especially  if   it  is   carried  to   a 
morbid  extent.     This  muco-pus  must  not  be  confounded  with  the 
abundant  white  secretion  which  is  frequently  found  in  this  region, 
and  which  is  the  result  of  congestion,  and  not  of  inflammation. 
Sometimes    the    inflamed   cervix   presents    membranous    patches, 
which  are  principally  observed  around  the  0s,  though  they  may 
occur  on  any  part  of  the  cervix. 

423.  In  nearly  every  case  of  inflammation  of  the  cervix  uteri, 
there  is  a  morbid  dilatation  of  the  cervical  cavity,  and  to  this  dila- 
tation, Dr.  Bennet  attaches  great  importance,  as  a  pathognomonic 
symptom.     He  says  :  "  Whenever  the  finger,  instead  of  passing 


INFLAMMATION    OF    THE    CERVIX.  215 

over  a  scarcely  perceptible  orifice,  meets  with  a  well-marked 
depression,  into  which  its  extremity  may  be  inserted  to  a  greater 
or  less  extent,  we  may  conclude  that  inflammation,  with  or  with- 
out ulceration,  is  present,  and  it  becomes  advisable  to  pursue  the 
investigation  further,  so  as  to  ascertain,  by  ocular  inspection,  in  a 
satisfactory  manner,  the  real  state  of  the  parts.  The  mucous 
membrane  that  lines  the  cavity  of  the  cervix,  when  inflamed, 
presents  a  dark,  livid  color,  which  may  be  traced  with  the  eye  to 
a  considerable  depth,  by  depressing  with  the  sound  the  lower  lip 
of  the  os.  This  surface  bleeds  easily  on  being  touched  with  a 
probe,  especially  if  excoriated  or  ulcerated,  which  is  not  the  case 
in  the  healthy  condition.  The  inflamed  mucous  membrane  of  the 
cervical  canal  also  secretes  muco-pus  in  more  or  less  abundance, 
and  this  muco-pus  filling  up  the  cavity,  can  often,  with  difficulty, 
be  wiped  away.  I  generally  use,  for  that  purpose,  a  small  piece 
of  cotton,  inserted  into  the  cleft  of  the  fluid  caustic-holder,  which 
may  be  passed  into  the  cavity  of  the  cervix,  owing  to  its  dilated 
state,  and  with  Avhich  the  mucus  may  be  removed.  Even  when 
there  is  no  pus  present,  the  cavity  of  the  cervix  is  often  com- 
pletely filled  with  a  glairy,  transparent  mucus,  evidently  secreted 
by  the  mucous  follicles  of  the  inflamed  lining  membrane.  This 
glairy  mucus,  which  may  be  compared  to  the  uncooked  white  of 
an  egg,  has  much  attracted  the  attention  of  writers  on  female 
discharges,  and  is  considered  to  be  secreted  by  the  uterine  organs 
generally,  as  the  result  of  debility ;  whereas,  in  reality,  it  is 
secreted  by  the  cavity  of  the  cervix,  and  is  nearly  always  the 
concomitant  of  inflammation.  It  is  sometimes  produced  in  very 
great  abundance,  and  constitutes  one  of  the  principal  forms 
of  the  vaginal  discharge  commonly  called  the  whites.  "  The 
presence  of  great  quantities  of  this  glairy  mucus,  along  Avith  an 
open  state  of  the  os  uteri,  may  be  considered  as  pathognomonic  of 
inflammation  of  the  cavity  of  the  cervix."  With  inflammation  of 
the  cervix,  there  is  frequently  an  extension  of  it  to  the  upper 
part  of  the  vagina,  which  will  be  congested  and  inflamed,  and 
present  the  deep  vascular  hue  and  the  muco-purulent  secretion 
which  characterize  these  conditions  in  a  mucous  membrane.  If 
the  disease  be  severe,  and  sometimes  when  it  is  not,  the  vagina 


216  DISEASES     OF     WOMEN. 

and  the  vulva  are  congested,  swollen,  and  tender,  and  more  of 
less  inflamed.  Pruritis  of  the  vulva  is  not  an  uncommon 
symptom  of  this  affection  ;  it  often  becomes  very  distressing,  and 
may  or  may  not  be  accompanied  with  inflammation  or  erosion  of 
some  part  of  the  external  genitals.  In  these  cases  the  common 
local  applications  for  the  relief  of  this  symptom  will  prove  of  but 
little  avail  until  the  diseased  condition  of  the  cervix  is  removed. 

424.  This  inflammation,  when  severe  and  of  long  continuance, 
sometimes  extends  to,  or  exercises  a  morbid  influence  on,  the 
the  rectum  and  bladder.  The  rectum  is  very  frequently  affected 
in  chronic  uterine  disease,  whether  of  the  body  or  the  cervix.  If 
the  cervix  is  enlarged  and  indurated,  it  is  generally  thrust  back 
mechanically  so  as  to  press  on  the  lower  bowel,  the  body  of  the 
uterus  remaining  in  situ  or  being  carried  forward.  In  this  case, 
the  pressure  on  the  lower  bowel  is  attended  with  the  same 
distressing  results  as  when  it  is  the  body  of  the  uterus  that  is 
retroverted  and  pressed  upon  the  rectum.  The  faeces,  meeting 
with  a  physical  obstruction  to  their  passage  into  the  lower  part  of 
the  rectum,  accumulate  above,  and  keep  the  upper  part  of  the 
bowel  permanently  distended.  Their  passage  is  also  attended 
with  pain,  especially  if  they  are  solid,  owing  to  the  contents  of  the 
bowel  having  to  lift  up  the  inflamed  and  indurated  organ  that 
obstructs  their  exit.  This  pain,  however,  is  not  near  so  great  as 
when  the  body  of  the  uterus  is  affected,  owing  to  its  greater 
sensibility.  Hemorrhoids  are  not  an  unfrequent  complication 
with  this,  as  well  as  with  other  forms  of  uterine  disease.  The 
attacks  of  piles  occur,  most  frequently,  at  the  period  of  menstrua- 
tion, when  the  pelvic  irritability  and  congestion  are  at  the  greatest 
hight.  From  the  close  relation  of  the  bladder  to  the  uterus,  it  is 
nearly  as  liable  as  the  rectum  to  suffer,  when  the  neck  of  the 
uterus  is  the  seat  of  inflammatory  disease.  The  bladder  and 
urethra  may  become  congested  and  irritable,  giving  rise  to  pain 
above  and  behind  the  pubis,  accompanied  by  a  frequent  desire  to 
pass  water,  to  difficulty  in  its  excretion,  and  to  heat  and  scalding 
in  the  urethra  as  it  passes.  Owing  to  the  fact  that  the  cervix 
uteri  is  very  scantily  supplied  with  nerves,  inflammation  of  it  is 
rarely  marked  by  pain  in  the  part  affected ;  thus,  pain  is  seldom 


INFLAMMATION     OF    THE     CERVIX.  217 

felt  behind  the  pubis,  the  anatomical  seat  of  the  diseased  cervix. 
Sometimes,  however,  the  diseased  cervix  becomes  very  sensitive  to 
pressure,  so  much  so  that  coitus  produces  extreme  pain.  The 
locality  of  the  pain  in  this  disease  is  in  the  lumbo-sacral,  the 
ovarian,  and  the  lower  hypogastric  regions.  The  first  of  these,  or 
the  pain  in  the  small  of  the  back,  is  the  most  constant,  though  it 
is  not  especially  symptomatic  of  this  disease;  for  it  may,  and 
often  does  arise  from  any  of  the  many  diseases  of  this  region.  On 
the  contrary,  the  ovarian  pain  may  be  considered  all  but  pathog- 
nomonic  of  this  affection.  According  to  Dr.  Bennet,  "  in  nine 
cases  out  of  ten,  it  is  the  left  ovarian  region  alone,  and  not  the 
right,  or  both,  that  is  the  seat  of  pain.  This  localization  of  the 
pain  produced  by  inflammation  and  ulceration  of  the  cervix  uteri, 
in  the  left  ovarian  region,  is,  perhaps,  connected  with  some 
peculiarity  of  the  distribution  of  the  uterine  nerves,  but  I  have, 
hitherto,  been  unable  to  discover  any  anatomical  reason  for  the 
preference  thus  shown.  The  fact,  however,  is  undeniable,  and 
renders  the  existence  of  a  dull,  aching,  constant,  circumscribed 
pain  in  the  left  ovarian  region,  all  but  pathognomonic  of  inflam- 
matory disease  of  the  cervix  uteri."  The  hypogastric  pain  is  of 
much  rarer  occurrence  than  either  of  the  others  ;  it  arises  from 
pain  in  the  neck  of  the  uterus,  and  is  felt  above  and  behind  the 
pubis.  It  is  seldom  circumscribed,  like  the  ovarian  pain,  but 
radiates  all  over  the  lower  hypogastric  region. 

425.  Inflammation  of  the  cervix  uteri  very  rarely  exists  for 
any  length  of  time,  without  unfavorably  modifying  the  function 
of  menstruation.  Thus,  it  very  often  produces  dysmenorrhea, 
and  when  menstruation,  previously  easy,  becomes  painful,  we  may 
suspect  the  presence  of  inflammation  of  the  cervix.  It  may  also 
influence  the  periodicity  or  quantity  of  the  menstrual  excretion, 
either  lengthening  or  shortening  the  intervals,  or  the  duration  of 
the  flow;  or  increasing  or  diminishing  the  quantity.  From  the 
commencement  of  inflammation  of  the  cervix  uteri,  the  health 
gradually  deteriorates,  though  this  does  not  become  marked  until 
it  has  continued  for  some  time,  without  the  patient  has  naturally 
a  feeble'  constitution.  The  first  symptoms  of  constitutional 
affection  will  be  observed  in  the  function  of  digestion,  caused  bj 


218  DISEASES     OF    WOMEN. 

a  transmission  of  the  local  irritation  to  the  sympathetic  nerves 
supplying  the  abdominal  viscera.  We  see  an  illustration  of  this 
sympathetic  connection  between  the  uterus  and  digestive  organs, 
in  the  first  months  of  pregnancy,  in  the  morning  sickness, 
depraved  or  vitiated  appetite,  etc.  The  extent  to  which  this 
function  becomes  morbidly  modified,  varies  in  different  individuals; 
thus,  in  some,  digestion  is  merely  weakened,  while  in  others  all 
the  symptoms  of  dyspepsia  are  manifested,  sometimes  in  an  aggra- 
vated degree.  The  appetite  may  be  either  diminished  in  these 
cases,  or  it  may  be  morbidly  increased  or  perverted.  With  this 
disturbance  of  the  digestive  functions,  there  is  often  a  torpor  of 
the  excretory  organs,  the  skin  is  harsh  and  rough  to  the  touch, 
the  kidneys  do  not  properly  perform  their  functions,  and  the 
bowels  are  either  habitually  constipated,  or  else  there  is  an 
alternation  between  constipation  and  diarrhea,  the  patient  being 
affected  with  first  one  and  then  the  other.  From  what  has  been 
already  stated,  we  should  suppose  that  if  the  disease  continues,  as 
it  often  does,  for  months  and  even  years,  the  patient  would 
become  greatly  debilitated,  and  this  is  the  case ;  patients  laboring 
tinder  this  affection  present  a  blanched  and  ex-sanguined  appear- 
ance ;  they  are  listless,  having  no  desire  to  take  exercise,  and  are 
often  the  subjects  of  hysteria. 

426.  Treatment. — The  treatment  of  inflammation  of  the  cervix 
uteri  will   have   to  be   varied    according  to  the  severity   of  the 
disease,  the  extent  of  the  inflammation,  the  length  of  time  it  has 
existed,   and   the   degree   of   constitutional   disturbance    present. 
Simple  inflammation  of  the  cervix  of  recent  date,  rarely  comes 
under  the  care  of  the  physician  ;  it  is  only  when  the  inflammation 
has  extended  to  the  deep,  tissues  of  the  cervix,  or  has  continued 
so  long,  that  the  general  health  is  affected,  that  he  is  consulted. 

427.  In  the  treatment  of  this  affection,  we  make  use  of  both 
general   and  local   medication,   the  first  to   restore   the    general 
health,   correct  the   secretions,  and  to  subdue  the  inflammation; 
the  local  measures  are  entirely  directed  to  subdue  the  local  inflam- 
matory process.     These  measures  will  be  separately  considered, 
though  used  together. 

428.  In  the  first  stages  of  inflammation,  should  the  physician 


INFLAMMATION     OF     THE     CERVIX.  219 

bo  called,  and  recognize  the  disease  as  inflammation  of  the  cervix, 
such  general  measures  should  be  used  as  we  adopt  for  inflammation 
of  other  parts  of  the  system.  Thus,  the  patient  should  be  kept 
quiet,  in  the  horizontal  position,  the  sedatives  given  in  the  usual 
doses,  with  such  other  remedies  as  may  be  specially  indicated. 
Those  named  under  the  head  of  congestion  of  the  cervix  may  be 
thought  of  here,  though  we  are  not  restricted  to  such  as  specially 
influence  the  uterus.  The  Macrotys  and  Caulophyllum  are  admi- 
rable remedies  in  many  cases,  and  associated  with  Aconite  will 
frequently  remove  the  unpleasant  symptoms  in  the  early  stage. 
The  torpid -condition  of  the  abdominal  viscera  or  intestinal  canal 
may  be  rectified  by  the  use  of  the  small  dose  of  Podophyllin  and 
Hydrastia  ;  nausea  and  abdominal  pains  by  Nux  ;  and  abdominal 
tenderness  by  Dioscorea.  Harsh  remedies  in  the  form  of  cathar- 
tics and  other  means  are  to  be  avoided  ;  and  even  local  applica- 
tions over  the  hypogastrium  are  frequently  harmful  rather  than 
of  benefit,  as  also  are  injectionsin  the  earl}-  stage.  The  Apis  may 
be  referred  to  as  especially  a  good  remedy  when  there  is  burning 
and  difficulty  in  passing  urine;  and  the  Rhus  when  there  is  the 
frontal  headache. 

Where  the  disease  has  continued  for  some  time,  affecting  the 
deep  tissues  of  the  cervix  and  its  cavity,  producing  a  plentiful 
leucorrheal  discharge,  and  affecting  the  general  health  of  the 
patient,  other  measures  will  have  to  be  resorted  to.  Here,  the 
disease  is  essentially  chronic  in  its  character,  and  the  tissues  have 
become  habituated  to  the  morbid  action,  which  has  no  tendency  to 
terminate  naturally  in  resolution ;  in  this  stage  of  the  disease,  we 
generally  find  the  dyspeptic  symptoms  already  spoken  of.  Here, 
it  will  be  necessary  to  employ  such  measures  as  will  restore  the 
general  health  of  the  patient,  as  Avell  as  to  counteract  the  local 
disease.  From  the  group  of  remedies  that  control  the  inflamma- 
tory process,  select  those  best  adapted  to  the  case  in  hand,  and 
add  such  uterine  remedies  as  may  be  indicated.  It  may  be  that 
we  will  want  some  of  the  saline  diui'etics,  the  salts  of  Iodine  or 
Bromine,  remedies  that  influence  the  intestinal  canal,  special 
remedies  for  the  skin,  etc.  Especial  attention  is  to  be  given  to 
the  menstrual  and  reproductive  function.  Sometimes  the  use  of 
Macrotys,  Pulsatilla  and  Viburnum,  to  give  normal  menstruation, 


220  DISEASES     OF     WOMEN. 

will  be  speedity  followed  by  a  cure  of  the  inflammation.  In  other 
cases,  remedies  like  the  Hamamelis,  that  strengthen  the  pelvic 
circulation,  will  be  demanded.  The  constipation  of  the  bowels  is 
best  overcome  by  a  drop  of  the  tincture  of  Nux  in  the  morning, 
with  abdominal  frictions — Quinine  inunction  being  a  good  thing 
in  many  cases. 

In  order  to  quiet  the  sympathetic  irritation  of  the  stomach 
that  frequently  exists,  it  will  be  necessary  to  apply  counter-irrita- 
tion over  the  lower  lumbar  portion  of  the  spine,  and  sometimes 
over  the  epigastric  region ;  the  irritating  plaster  is  '  the  best 
counter-irritant  that  can  be  used.  When  it  is  applied  over  the 
stomach,  there  is  generally  no  necessity  of  continuing  it  until  it 
produces  free  suppuration,  a  slight  degree  of  irritation  kept  up. 
by  it,  accomplishing  all  that  is  desired.  It  is  very  important  in 
treating  these  cases,  that  the  excretory  organs  should  be  stimu- 
lated to  a  full  performance  of  their  functions;  thus  the  skin 
should  be  kept  in  a  healthy  condition  by  the  use  of  baths,  either 
warm  or  cold,  and  by  brisk  frictions,  and  the  kidneys  stimulated 
to  a  normal  performance  of  their  functions  by  the  occasional  use 
of  diuretics.  In  addition  to  the  use  of  general  remedies  referred 
to  above,  we  may  greatly  assist  in  the  removal  of  the  local  inflam- 
matory process,  by  the  use  of  internal  remedies.  For  this  pur- 
pose, we  may  use  with  much  benefit  the  Caulophyllum,  Helonias, 
Senecio,  Actaea,  and  Trillium.  These  agents  exercise  a  special 
influence  on  the  uterus,  removing  congestion,  subduing  inflamma- 
tion and  increasing  the  tonicity  of  the  uterine  organs.  They 
may  be  given  either  separately,  or  in  combination  with  the  reme- 
dies named  above.  The  Iodide  of  Iron  has  likewise  been  used 
with  considerable  benefit ;  the  solution  is  the  best  form  in  which 
it  can  be  administered;  the  Off.  Liquor  Ferri  lodidi,  dose  from 
gtt.  xx.  to  xxxx. 

429.  Among  the  local  measures  employed,  vaginal  injections, 
either  of  water  only,  or  of  water  containing  some  medicinal 
substance  in  solution,  are  among  the  most  valuable  means  of 
treatment  in  this  disease.  Special  directions,  however,  will  have 
to  be  given  to  the  patient,  or  her  nurse,  in  reference  to  the  proper 


INFLAMMATION    OF     THE     CERVIX.  221 

mode  of  using  them,  or  they  will  be  found  of  little  avail.  In 
order  to  obtain  the  full  benefit  of  vaginal  injections  in  diseases  of 
the  uterus,  it  is  necessary  that  they  shall  be  brought  in  contact 
with  the  neck  of  the  uterus,  and  be  retained  a  sufficient  length  of 

O 

time ;  in  order  to  administer  these  injections  properly,  the  patient 
should  lie  upon  her  back,  with  her  hips  elevated,  so  that  the  fluid 
may  gravitate  toward  the  cervix  uteri ;  the  female  syringe  used 
should  be  introduced  to  the  cervix,  and  when  withdrawn,  the  vulva 
should  be  compressed  with  a  napkin,  in  order  to  retain  the  fluid  in 
contact  with  the  cervix  for  a  sufficient  length  of  time.  If  these 
directions  are  not  given,  the  probability  is,  that  the  injections  will 
be  used  in  a  standing  or  sitting  position,  the  natural  consequence 
of  which  would  be  that  the  fluid  would  immediately  escape  from 
the  vagina  as  soon  as  ejected  from  the  syringe ;  or  the  syringe 
might  be  only  partially  introduced,  the  injection  not  reaching  the 
cervix  at  all;  or  if  compression  is  not  used  over  the  vulva,  the 
natural  contractility  of  the  vagina  expels  the  injection  before  it 
has  remained  sufficiently  long  to  prove  effective. 

430.  The  best  syringe  that  can  be  used  to  give  these  injections, 
is  the   pump-syringe,  fitting  it  to  a  vaginal  tube  about  six  inches 
in  length.     With  this  syringe  any  quantity  of  fluid  required  can 
be  used  for  an  injection,  without  withdrawing  the  syringe,  as  has 
to  be  done  when  the  common  small  female  syringes  are  used.     In 
the  place  of  this  instrument,  a  large  metal  syringe,  fitted  with  a 
vaginal  tube  will  be  found  to  answer  a  very  good  purpose.     If  the 
common  female  syringe  is  used,  they  should  be  obtained  as  long 
and  as  large  as  can  be  well  used. 

431.  Water,  either    hot    or  cold,  deserves  the  first  place  in  the 
description   of  these  injections,  not  only  from  its   importance  in 
cleansing  the  cervix  and  vagina  from  morbid  secretions,  but  also 
for  its    therapeutic  effect.     Injections   of  water,  either     hot      or 
cold,   should   be    used  in   this   disease   as   often   as  twice  a  day, 
whatever  other  local  means  may  be  resorted  to,  in  order  to  remove 
the  morbid  secretions  of  the  diseased  parts,  and  keep  the  vagina 
in  a  clean  and  healthy  condition.     It  will  be  recollected  that  in 
married   women,  the  upper  part  of   the  vagina,  or  that  inclosing 
the  cervix,  is  somewhat  dilated,  and  that,  when  healthy,  it  closes 


222  DISEASES     OF     WOMEX. 

on  itself  in  its  entire  extent.  As  a  necessary  result  of  this 
structural  condition,  the  muco-purulent  matter  secreted  by  the 
inflamed  cervix,  when  it  is  not  large  in  quantity,  is  retained 
around  the  cervix,  where  it  tends  to  keep  up  and  perpetuate  the 
nflammation,  and  gives  rise  to  ulceration.  It  will  thus  be  seen, 
that  much  depends  upon  the  use  of  water  as  a  wash  to  cleanse 
the  parts.  In  using  water  for  this  purpose,  a  sufficient  quantity 
should  be  injected  to  accomplish  this  object.  Warm  water  used 
as  an  injection,  acts  as  an  emollient,  softening  and  relaxing  the 
tissues,  and  subduing  irritation  ;  in  some  cases,  it  will  be  found  to 
exert  a  better  influence  than  the  cold;  this  will  be  especially  the 
case  where  the  inflammation  is  acute,  where  it  has  extended  to  the 
vagina,  or  where  the  patient  is  very  nervous  or  irritable.  Cold 
water  is  a  powerful  tonic  and  astringent,  and  maybe  used  very 
beneficially  toward  the  subsidence  of  the  inflammation,  arid  it 
should  always  be  continued  for  some  time  after  the  disease  has 
been  subdued,  to  prevent  a  relapse.  When  there  is  much  irritation 
of  the  cervix  and  upper  part  of  the  vagina,  it  will  be  necessary 
to  use  emollient  or  narcotic  injections ;  a  decoction  of  marsh- 
mallow,  or  of  slippery-elm  bark  will  be  found  very  useful,  from 
their  soothing  effect  upon  the  inflamed  mucous  surface.  I  have 
also  used  a  decoction  of  the  leaves  of  the  stramonium,  as  an 
injection  in  these  cases,  with  marked  benefit. 

In  other  cases,  where  there  is  no  irritability  present,  or  where 
it  has  been  removed,  other  injections  may  be  used  to  remove  the 
inflammation.  For  this  purpose,  the  injection  recommended  by 
Prof.  T.  V.  Morrow  may  be  used  with  much  advantage. 

R   Pulvis,  Macrot3Ts    Racemosa, 

Geranium  Maculatum,  aa.  Sij. 
Aqua  Bullions,  Oct.  iv.* 

Let  it  boil  for  half  an  hour,  strain,  and  use  from  four  to  six 
ounces,  as  an  injection,  twice  a  day.  This  injection  is  astringent, 
and  it  likewise  exerts  a  peculiar  influence  on  the  vaginal  walls 
and  cervix  uteri,  removing  congestion  and  inflammation,  and 
giving  tone  to  the  mucous  membrane  lining  the  vagina  and 


INFLAMMATION"     OF     THE     CERVIX     UTERI.        223 

vaginal  portion   of   the   cervix.     Another  injection,   that  will  be 
found  very  beneficial  in  these  cases,  is  composed  of 

R    Ilydrastis  Canadensis,  Sss. 
Rhus  Glabrum,  5ij. 
Aqua  Bullions,  Oct.  ij. 

Let  it  boil  for  fifteen  or  twenty  minutes,  strain,  and  use  as  an 
injection.  A  solution  of  Salicylic  Acid  and  Borax,  of  Chlorate  of 
Potash,  Sulphate  of  Zinc,  or  sometimes  of  Hydrate  of  Chloral, 
may  be  used  as  a  vaginal  injection  with  benefit. 

432.  If  there  is  a  copious  secretion  of  mucus,  or  muco-purulent 
matter,  the  canal  of  the  cervix   should  be  carefully  examined  in 
regard  to  its  degree  of  dilatation,  and  the  distance  this  extends 
up  it,   and   if  it   is  much   affected  by  the  disease,  the  tenacious 
mucus  should  be   removed   in    the   manner   heretofore  stated,  in 
order  to  allow  the  injections  to  come  in  contact  with  all  parts  of 
the  cavity. 

433.  By  the  judicious  use   of    the  remedies    above-named,    a 
majority  of  these  cases  may  be  radically  cured  ;  some  few  cases, 
however,  after  improving  for  a  week  or  ten  days,  will  then  stop, 
no  further  benefit  appearing  to  be  derived  from  their  use.     In  the 
most  of  these  cases,  the  canal  of  the  cervix  will  be  found  to  be 
the    part   mostly    involved,  and    the    treatment   will    have  to  be 
directed   to  it.     The  quickest  way  to  remove  the  diseased  con- 
dition of  the  cervical  cavity  is,  to  apply  to  it,  as  far  as  dilated,  by 
means  of   a  camel-hair  pencil,  a  strong  solution   of   the  Sesqui- 
Carbonate  of  Potassa,  or  Nitrate  of  Silver. 

RESULTS  OF  INFLAMMATION  OF  THE  CERVIX  UTERI. 

434.  Inflammation  of  the  cervix  uteri  gives  rise   (directly)  to 
hypertrophy,  erosions,  granular  elevations  of  different  kinds,  and 
to  ulceration.     It  may,  likewise,  be  a  cause  of,  or  greatly  aggra- 
vate,   dysmenorrhea,   amenorrhea,    menorrhagia,   and    leucorrhea. 
Its   relation   to  these   diseases  will,   however,   be   hereafter   con- 
sidered under  their  separate  heads.     Does  inflammation  ever  give 
rise  to  cancer,  corroding  ulcer  of  the  os  uteri,  or  to  cauliflower 


224  DISEASES    OF    WOMEN. 

excrescence  ?  It  has  been  thought,  by  many  writers,  that  inflam- 
mation of  the  uterus  is  a  frequent  cause  of  cancer.  This  opinion, 
however,  does  not  appear  to  be  founded  on  the  results  of  careful 
observations.  As  inflammation  of  the  cervix  uteri  gives  rise  to 
the  formation  of  a  true  and  normal  pus,  and  very  frequently  to 
ulceration,  with  its  secretion  of  normal  pus,  I  should  consider  that 
when  it  presented  this  character  it  was  directly  opposed  to  cancer 
formation.  My  reasons  for  this  opinion  are,  that  cancer  is  never 
accompanied  by  an  exudation  of  normal  pus,  neither  have  I  been 
able  to  learn  that  it  ever  has  arisen  as  a  consequence  of  any 
morbid  action  producing  this  exudation.  The  formation  of  normal 
pus,  in  every  case,  appears  to  be  diametrically  opposed  to  the 
existence  of  any  malignant  growth.  This  is  well  shown  in  the 
treatment  of  cancer,  after  the  diseased  mass  is  removed,  either  by 
the  knife  or  caustic,  free  suppuration  is  indispensable  to  prevent 
its  reproduction,  and  where  this  normal  pus  secretion  is  main- 
tained, it  rarely,  if  ever,  recurs.  If,  however,  a  low  degree  of 
inflammation  exists,  without  exudation,  or,  if  the  exudation  is 
thin,  variously  discolored,  presenting  none  of  the  characteristics 
of  the  normal  bland  pus,  we  then  have  the  very  condition  of  the 
parts  necessary  to  the  formation  of  malignant  growths.  In  one 
case  that  I  had  the  opportunity  to  observe,  the  rise  and  progress 
of  carcinoma  of  the  cervix,  this  low  degree  of  inflammation  was 
present  before  the  development  of  the  cancerous  growth,  and  I 
have  no  doubt  that  it  was  the  proximate  cause.  These  observa- 
tions will  also  apply  equally  well  to  those  cancroid  growths, 
cauliflower  excrescence,  and  corroding  ulcer. 

435.  Dr.  Bennet  formerly  entertained  the  opinion  that  inflam- 
mation was  a  frequent  cause  of  cancer  of  the  uterus ;  his  views, 
however,  have  since  been  changed.  In  the  last  edition  of  his 
work,  he  says  :  "  Clinical  experience  has  led  me  to  modify  the 
opinion  I  formerly  entertained,  in  common  with  the  rest  of  the 
profession,  respecting  the  frequency  of  cancerous  degenerescence 
of  chronic  inflammatory  tumors.  During  the  last  ten  or  twelve 
years,"  I  have  followed  the  progress  of  many  cases  of  uterine 
inflammation,  and  have  not  seen  a  single  instance  of  inflammatory 
disease  thus  degenerate.  In  some  instances,  I  have  been  told  in 


HYPERTROPHY     OF     THE     CERVIX     UTERI.          225 

consultation,  that  the  disease  respecting  which  my  opinion  was 
required,  although  then  evidently  cancerous,  had  at  first  been 
merely  inflammatory.  In  these  cases,  however,  the  diagnosis  of 
my  informants  could  not  be  relied  upon,  and  the  antecedents  of 
the  patient  were  also  completely  at  variance  with  their  view  of  the 
evolution  of  the  morbid  phenomena.  On  the  other  hand,  all  the 
cases  of  cancerous  disease  that  I  have  witnessed  during  the 
before-mentioned  period,  have  been  evidently  such  from  the  time 
they  first  came  under  my  observation." 

HYPERTROPHY  OF  THE  CERVIX  UTERI. 

436.  Hypertrophy  of  the  uterine  tissue  is,  in  a  great  majority 
of  cases,  confined  to  the  cervix,  though  sometimes  it  extends  to 
the   body  of  the   uterus.     Inflammation   may  be   considered  the 
cause  of  hypertrophy  in  nearly  every  instance,  the  inflammatory 
products  not  being  reabsorbed,   but  becoming   organized,  or  the 
inflammation  being  of  a  lower  kind,  the   circulation  of  the  blood 
increased,  the  textural  nutrition  of  the  organ  becomes  morbidly 
exaggerated.     Hypertrophy  of  the  cervix  uteri  may,  or  may  not 
be  accompanied  with  induration  ;  one  of  the  first  effects  of  inflam- 
mation is  to  produce  congestion  and  enlargement  of  the  cervix  ; 
the   enlargement  may  continue   for  years,  the  cervix  being   soft 
and    elastic.      This,    however,    is    not    very    common,   induration 
generally  accompanying  hypertrophy. 

437.  Hypertrophy  of   the   cervix   may  arise   either  before  or 
after  ulceration.     Dr.  Bennet  thinks  it  to  be  more  frequently  the 
sequela,  than  the  cause  of  ulceration:  he  says,  "I  have  very  often 
been  able  to  follow  the  extension  of  the  inflammation  accompany- 
ing ulcerative  disease  to  the  deeper-seated  tissues,  and  to  watch 
the    gradual    manifestation,    under    its    influence,  of   deep-seated 
induration.     Thus,  I  have  frequently  seen  cases  in  which  a  slight 
ulceration  was  at  first  the  only  lesion,  and  in  which  the  general 
induration,  which    subsequently  made   its   appearance,  gradually 
became  more  and  more,  marked    as   the   ulceration  increased  in 
extent.     I  am  also  continually  meeting  with  ulceration  confined  to 
one  lip,  accompanied  by  induration,  and  hypertrophy  of  that  lip 
only.     Although  I  thus  consider  induration  and  hypertrophy  of 

15 


226  DISEASES     OF     WOMEN. 

the  cervix  generally  to  be  the  result  of  extension  of  superficial 
inflammation  to  the  central  tissues,  to  be  the  sequela  and  not  the 
cause  of  ulceration,  the  reverse  may  take  place.  Induration  and 
enlargement  of  the  cervix  may  remain  as  a  result  of  general 
metritis,  and  by  the  irritation  which  it  produces  give  rise  to 
inflammation  and  ulceration  of  the  mucous  surface.  Whatever 
may  have  occasioned  the  inflammatory  induration,  if  it  persists,  it 
certainly  becomes  an  important  cause  of  local  disease,  continually 
reproducing  the  ulceration,  unless  means  be  taken  to  remove  it 
as  well  as  the  more  superficial  disease.  This  it  does  in  two  ways ; 
by  keeping  up  a  chronic  state  of  inflammation  of  the  organ,  in 
which  the  mucous  surface  participates,  and  by  the  friction  of  the 
hypertrophied  and  generally  prolapsed  cervix  against  the  parieties 
of  the  vagina  occasions." 

438.  Symptoms. — The  symptoms   accompanying   hypertrophy* 
of  the  cervix  are  the  same  as  those  of  inflammation.     There  is, 
however,  a  greater  sense  of  weight  and  dragging  in  the   pelvic 
cavity,  and  a  sensation  of  pruritus  or  rawness.     On  making  an 
examination,  the  cervix  will  be  found  more  or  less  displaced,  and 
increased  in  size ;  this  increase  in  the  size  of  the  organ  may  be 
confined  to  one  lip,  or  involve  the  entire  cervix.     If  there  have 
been  previous  lacerations  in  labor,  the  indurated  cervix  may  be 
divided  into  lobes,  as  is  seen  in  the  plate.     If  it  is  likewise  indu- 
rated, it  will  be  dense  to  the  touch,  though  not  presenting  the 
rough  feeling  that  distinguishes  malignant  disease;    if  it  is  not 
indurated,  it  will   be  found  soft  and  elastic.      In   all  cases  the 
external  orifice  will  be  found  enlarged,  but  instead  of  the  circular 
or  nearly  circular  orifice,  it  will  be  transverse,  presenting  well- 
defined   lips.     The   cervix  will   also   be   more   red,  smooth,  and 
moist,  than  natural. 

439.  Treatment. — The  first  point  in  the  treatment  of  hyper- 
trophy of  the  cervix,  is  to  subdue  the  existing  local  inflammation. 
For  this  purpose  the  means  heretofore  recommended  should  be 
employed.     If  the  patient  be  debilitated,  the  same  tonic  course 
should  be  pursued  to  build  up  the  health  of  the  patient,  keeping 
the  secretions  and  excretions  in  their  normal  healthy  condition. 
These  means  may  have  to  be  employed  for  a  month  or  two  before 


HYPERTROPHY     OF     THE     CERVIX     UTERI.  227 

the  low  degree  of  inflammation  accompanying  hypertrophy  is 
entirely  subdued.  If  after  this  the  hypertrophy  still  continues, 
more  energetic  means  will  be  required.  The  use  of  Macrotys  with 
Pulsatilhi  in  small  doses,  will  sometimes  give  speedy  relief,  though 
to  effect  a  cure  it  must  be  continued  for  a  number  of  months — at 
least  to  the  extent  of  regulating  the  menstrual  flow.  AVIien 
oedema  is  a  marked  symptom,  especially  when  associated  with 
menorrhagia,  the  Apocynum  will  be  indicated.  Associated  with 
disease  of  the  mammary  glands,  or  lymphatic  enlargement,  1 
would  advise  Phytolacca;  and  with  disease  of  the  thyroid  gland, 
the  Iris.  The  Hamamelis  is  an  excellent  remedy  in  those  cases 
marked  by  venous  fullness,  and  a  lax  condition  of  the  tissues  clos- 
ing the  outlet  of  the  pelvis.  It  may  be  given  in  doses  of  from  ten 
to  thirty  drops  four  times  a  day,  and  may  also  be  used  as  a  local 
application  to  the  hypogastrium,  and  as  an  injection.  Some  of 
the  remedies  known  as  uterine  tonics  are  also  available  here,  as 
the  Senecio,  Helonias,  etc.  But  whatever  is  used  should  be  se- 
lected with  care,  and  it  may  be  any  remedy  of  the  materia  med- 
ica,  if  there  is  a  specific  indication  for  it,  I  have  had  quite  as 
much  benefit  from  Bryonia.  Kims,  Nitric  Acid,  Baptisia,  and  rem- 
edies of  this  class,  as  those  that  have  direct  action  on  the  uterus. 
440.  Among  the  local  applications  that  have  been  used  to 
overcome  hypertrophy  of  the  uterus,  I  might  mention  the  Sesqui- 
Carbonate  of  Potassa,  Nitrate  of  Silver,  Potassa  Cum.  Calc., 
and  the  Potassa  Fusa.  In  many  cases  of  hypertrophy,  with  but 
a  slight  degree  of  induration,  the  application  of  the  Sesqui- 
Carbonate  of  Potassa  to  the  enlarged  cervix,  in  addition  to  the 
last  injection  recommended  in  the  treatment  of  inflammation  of 
the  cervix,  will  be  found  to  quickly  remove  the  enlargement.  In 
using  this  agent,  a  saturated  solution  should  be  made,  and 
applied  to  the  entire  cervix,  by  means  of  a  camel's-hair  pencil ;  it 
should  also  be  applied  to  the  cervical  cavity  as  far  as  it  is  open. 
The  application  of  this  caustic  produces  but  little  pain,  and  is 
followed  by  an  increased  secretion  from  the  parts,  which,  how- 
ever, ceases  in  from  one  to  two  days,  when  it  should  be  reapplied. 
The  application  of  this  caustic  should  be  followed  in  about  fifteen 
minutes  with  injections  of  cold  water,  made  slightly  acidulous 
with  vinegar.  The  Nitrate  of  Silver  is  also  recommended  in 


228  DISEASES    OF    WOMEN. 

these  cases,  applying  the  stick  nitrate  by  means  of  a  caustic- 
holder,  to  the  surface  of  the  cervix;  it  produces  a  white  film,  or 
superficial  eschar,  which  falls  off  in  the  course  of  two  or  three 
days.  Its  application  is  rarely  followed  by  much  pain,  and  it 
day  be  reiipplied  when  the  eschar  falls  off;  of  the  two  agents,  I 
would  prefer  the  Potassa. 

441.  The  potassa  cum.  calce.  and  the  potassa  fusa  are  em- 
ployed in  these  cases,  where  the  enlargement  of  the  cervix  is 
accompanied  with  induration,  and  in  which  other  measures  have 
been  found  unavailing.  The  potassa  cum.  calce.  is  preferred  by 
many  practitioners  to  the  potassa  fusa,  from  the  great  deliquescence 
of  the  latter  agent,  and  its  liability  to  run  down  the  sides  of  the 
speculum  and  form  an  eschar  in  the  bottom  of  the  vagina.  Dr. 
Bennet  uses  the  potassa  cum.  calce.  cast  into  sticks  like  the  nitrate 
of  silver ;  it  is  composed  of  two  parts  of  hydrated  potassa  and 
one  of  lime;  this  he  has  found  as  efficient  as  the  potassa  fusa. 
Dr.  Simpson  uses  the  latter  agent;  he  says,  "Having  found  inflam- 
matory enlargement  and  induration  of  the  tissues  of  the  cervix 
very  frequent  in  practice,  and  existing,  in  fact,  in  most  cases  of 
very  chronic  and  aggravated  leucorrhea,  and  in  some  cases  having 
mistaken  it  for  the  induration  and  ulceration  of  carcinoma,  etc., 
he  has  employed  in  these  cases  the  nitrate  of  silver,  potassa  cum. 
calce,  and  nitric  acid.  Latterly  he  had  abandoned  these  and  other 
escharotics,  and  now  always  uses  the  common  potassa  fusa.  He 
has  found  it  far  more  manageable,  speedy,  and  certain,  than  any 
other  method.  He  uses  it,  of  course,  through  the  speculum, 
applying  a  stick  of  it  freely,  with  a  proper  caustic-holder,  to  the 
ulcerated  and  indurated  tissues.  It  required  to  be  rubbed  or  held 
strongly  for  a  time  against  the  part  which  was  to  be  destroyed. 
In  general,  a  piece  three-quarters  of  an  inch  or  an  inch  long  was 
melted  down.  If  the  induration  is  extensive,  and  the  whole  can 
not  be  removed  at  once,  increased  action  and  absorption  are  set 
up  in  what  remains,  and  the  parts  adjacent  become  softened  and 
diminished  in  size.  He  has  never  seen  pelvic  cellulitis  or  any 
other  bad  result  follow." 

I  have  introduced  this  quotation  from  Dr.  Simpson's  work,  not 
only  for  the  purpose  of  showing  the  applicability  of  this  method 


HYPERTROPHY     OF     THE     CERVIX     UTERI.         229 

of  treatment,  and  the  extent  to  -which  it  may  be  used  without 
producing  any  bad  effects,  but  also  to  caution  the  reader  against 
tt  e  destruction  of  tissue,  which  appears  to  be  the  chief  motive  Dr. 
Simpson  has  in  view.  The  object  in  using  these  agents  is  not  to 
destroy  the  enlargement,  or,  in  other  words,  melt  the  enlarged 
cervix  down  to  a  natural  size  ;  but  to  modify  the  action  of  the 
part,  and  cause  an  increased  absorption.  After  the  cervix  has 
been  cauterized,  nature  sets  up  eliminatory  inflammation,  in  order- 
to  throw  off  the  eschar.  This  inflammation  extends  more  or 
less  to  the  hypertrophied  tissues,  according  to  the  size  of  the 
eschar,  causing  an  increased  absorption  as  well  as  an  increased 
elimination  from  the  hypertrophied  part,  by  the  copious  purulent 
discharge  which  usually  follows  for  two  or  three  days,  and  which 
continues  in  smaller  quantities  until  cicatrization  of  the  ulcer  left 
by  the  eschar  takes  place.  Under  the  influence  of  this  very 
simple  process,  the  effects  of  which  persist  during  twro  or  three 
weeks  from  the  date  of  cauterization,  any  amount  of  hypertrophy 
of  the  uterine  neck  may  be  gradually  and  safely  removed,  and  that 
without  much  suffering  to  the  patient. 

442.  Of  late  years  I  have  employed  local  means  much  less  fre- 
quently than  in  the  olden  time,  having  found  that  internal  remedies 
carefully  selected,  would  accomplish  the  object  quicker.  And  now 
when  I  use  them,  I  frequently  make  a  different  selection.  If  there 
is  ulceration  or  erosion  of  the  canal  or  the  cervix,  I  like  the  free 
application  of  nitric  acid  with  a  pine  pencil.  When  the  surface 
is  spongy,  and  secretes  a  muco-pus,  which  has  an  unpleasant  odor, 
the  permanganate  of  potash  may  sometimes  be  used  with  advan- 
tage, the  strength  varying  from  grs.x.  to  £j.,  to  water,  3j.,  accord- 
ing to  the  condition  of  the  case.  Carbolic  acid  and  glycerine 
may  also  be  thought  of  as  a  possible  local  remedy.  In  some  cases 
a  prescription  of- — R  Solution  of  persulphate  of  iron,  tinct.  opium, 
aa.,  applied  with  a  camel's  hair  pencil,  will  aid  in  lessening  the 
eize  of  the  cervix.  The  extract  of  Pinus  canadensis,  and  other  of 
the  vegetable  astringents,  may  also  be  used  for  the  same  purpose. 

"When  the  body  of  the  uterus  is  also  enlarged,  the  tissues  being 
full,  doughy,  and  evidently  atonic — very  much  like  the  enlarged 
spleen,  called"  ague  cake" — I  have  used  the  ointment  of  Uvedalia 


230  DISEASES     OF    WOMEN. 

with  excellent  results.  It  should  be  thoroughly  rubbed  in  over 
the  hypogastrium,  and  then  toasted  in  by  a  warm  iron  passed  over 
the  surface,  which  is  covered  with  flannel.  Advantage  may  also 
be  found  by  rubbing  the  perineal  tissues  with  it.  Quinine  in- 
unction must  not  be  forgotten  as  a  possible  means  in  some  unpleas- 
ant cases,  where  the  patient  has  suffered  from  chronic  ague.  Even 
the  rubbings  and  kneadings  of  the  "Swedish  movement 'cure" 
will  be  found  of  advantage.  And  the  use  of  electricity,  if  skill- 
fully applied,  may  be  made  to  take  the  place  of  other  treatment. 

443.  It  is  well  to  call  attention  to  the  necessity  of  proper  dress 
and  means  of  support  for  the  pelvic  organs.     It  will  not  do  for  a 
woman  suffering  from  uterine  hypertrophy  to  wear  her  clothing 
suspended  from  the  waist.     A.11  pressure  upon  the  abdomen  must 
be  removed,  and  the  skirts  and  clothing  supported  from  the  shoul- 
ders.    Corsets  are  made  which  come  down  over  the  abdomen  and 
hips,  that  serve  the  purpose,  but  in  the  majority  of  cases  it  is 
better  to  suspend  every  thing  from  the  shoulders.     Using  the  long 
abdominal  corset,  straps  may  be  carried  between  the  thighs,  and 
a  perineal  pad  for  support  worn.     Or  a  nicely  fitted  pelvic  band- 
age with  the  same  straps  for  perineal  support,  will  frequently  be 
of  much  service.     This  apparatus  is  figured  on  page  349. 

EROSIOX  OF  THE  CERVIX. 

444.  By  erosion  of  the  cervix  uteri,  we  understand  an  abrasion 
of  the  mucous  membrane  covering  it,   of  greater  or  less  extent. 
It  forms  the  first  stage  of  ulceration,  and  though  it  may  extend 
that  far,  yet,  it  very  frequently  remains  for  some  months  a  simple 
abrasion   of    the  mucous  membrane.      Erosion  of    the  cervix  is 
invariably  accompanied  by  inflammation,  being  a  result  of  that 
disease.     Dr.  Bennet  considers  all  breaches  of  continuity  in  the 
mucous  membrane  to  be  ulceration.     He  remarks :  "  That  when 
an  abrasion  or  excoriation  only  is  present,  the  cervix  is  generally 
of  a  vivid  red,  and  the  granulations  are  often  so  minute,  that  it  is 
difficult  at  first,  to  ascertain  whether  the  membrane  is  abraded  or 
merely  congested,  or  perceive  the  limits  of  the  ulceration,  when 
once  it  has  been  ascertained  to  exist.     The  doubt,  however,  may 
be  solved,  by  lightly  touching  the  suspected  surface  with  Nitrate 
of  Silver.     The  abrasion  immediately  assumes  a  much  Avhiter  hue, 


EROSIOX     OF     TIIK     CEKVIX.  231 

than  the  region  which  is  merely  congested,  and  its  margin  becomes 
Avell  defined  and  evident.  An  abraded,  excoriated  condition  of 
the  mucous  surface  is  generally  the  form  under  which  ulceration 
presents  itself  in  the  cavity  of  the  cervix;  granulations  of  any 
size  being  seldom  met  with  in  this  region.  In  virgins  also,  ulcera- 
tion often  presents  this  character,  especially  when  it  is  limited  to 
the  cavity  of  the  os." 

These  erosions  have  been  minutely  investigated  by  Dr.  Tylei 
Smith,  with  the  microscope;  he  says:  "  The  epithelium  of  the 
external  portion  of  the  os  and  cervix  uteri,  and  of  the  upper  por- 
tion of  the  vagina,  may  be  partly  or  entirely  removed ;  or  there 
may  be  morbid  patches  in  which  the  epithelium  is  here  and  there 
•wanting.  When  in  analogous  states,  the  epithelium  has  been 
removed  in  the  living  subjects  by  diseased  conditions,  the  mucous 
membrane  is  of  an  intensely  red  color,  from  the  presence  of  the 
naked  villi,  with  their  vascular  loops,  and  it  conveys  an  impression 
of  roughness  and  denudation  upon  examination  by  the  speculum. 
To  the  touch,  the'  abraded  surface  feels  erectile  and  velvety;  a 
term  which  has  been  very  commonly  applied  to  what  has  been 
considered  ulceration  of  the  cervix  and  os  uteri.  The  villi  do, 
indeed,  in  this  condition,  stand  out  somewhat  like  the  pile  of 
velvet,  and  in  some  cases  they  themselves  are  considerably  en- 
larged. In  other  cases,  there  is  not  merely  the  loss  of  the  dense 
epithelium,  but  the  villi,  both  of  the  external  surface  of  the  os  uteri, 
and  of  the  mucous  surface  within  the  labia  uteri  are  destroyed 
in  patches.  In  that  condition  of  the  os  uteri,  which,  on  examina- 
tion after  death,  would  be  pronounced  to  be  undoubted  superficial 
ulceration,  the  state  which  generally  obtains,  is  partial  or  entire 
loss  of  the  epithelial  layer  in  circumscribed  patches,  and  here 
and  there  the  loss  or  partial  destruction  of  the  villi.  This  gives 
an  eaten,  corroded  appearance  to  the  mucous  surface ;  such  a  con- 
dition of  the  os  may  be  limited  in  extent,  or  it  may  spread  over 
the  whole  of  the  os  and  the  external  cervix,  and  pass  within  the 
labia  uteri.  Sometimes  small  circumscribed  ulcers  are  seen-,  in 
which  the  denuded  or  partially  denuded  villi  are  found  surround- 
ing the  edge  of  the  small  ulcer ;  the  area  of  the  ulcer  itself  being 


232  DISEASES     OF     WOMEN. 

bare  of  villi,  or  the  ragged  debris  of  villi,  and  their  vascular  loops 
appearing  at  the  bottom  of  the  ulcer." 

445.  With  this  erosion  there  is  always  more  or  less  induration, 
the   tissues   about  it  being  slightly  thickened,  especially  at  the 
edges  ;  still,  the  edges  are  not  raised  or  everted,  either  in  simple 
erosion,    or    ulceration    following    inflammation.      The    discharge 
from  these  erosions  may  be  thin  and  sanious,  but  it  is  much  more 
frequently  purulent. 

446.  Symptoms. — When  we  consider  that  erosion  of  the  cervix 
is  but  a  result  of  inflammation  appearing  during  its  progress,  we 
would  not  expect  to  find  any  other  symptoms  present  than  those 
of  inflammation,  this  being  the  disease,  the  erosion  the  result. 

447.  Treatment. — If,  after  using  the  treatment  recommended 
for  inflammation,  the  erosion  does  not  heal,  or  if,  at  any  time,  it 
should  appear  to  be  progressing  toward  ulceration,  it  should  be 
freely  cauterized  with  the  nitrate  of  silver.     This  cauterization 
should   be  used   in   conjunction   with   the   injections   heretofore 
recommended.     There  are  but  few  cases  which  will  not  yield  to 
the  use  of  the  last  injection  named  in  the  treatment  of  inflam- 
mation. 

ELEVATIONS  THE  RESULT  OF  INFLAMMATION. 

448.  Elevations  of  different  kinds  may  arise  on  the  surface  of 
the  cervix  uteri,  as  a  result  of  inflammation.     They  may  arise 
either  from  the  surface  of  an  erosion,  from  an  ulcer,  or  from  the 
mucous  membrane  covering  the   cervix.     So  many  varieties  of 
these   elevations  have   been   noticed,    that   a  full  description  is 
impossible,   and  if  given,  would  be  of  but  little  benefit  to  the 
reader  without  it  was  accompanied  by  plates.     These  granula- 
tions, however,  must  not  be  considered  the  disease,  the  inflamma- 
tion accompanying  them  being  the  principal  affection,  and  the  one 
that  demands  the  attention  of  the  physician. 

449.  Fig.  18.  In  this  case  there  was  sub-acute  inflammation  of 
the  cervix,  with  its  symptoms.     On  examination,  the  uterus  was 
found  low  down  in  the  pelvis,  the  cervix  uteri  was  soft,  and  larger 
than  usual,  and  presented,  to  the  finger,  some  unevennesses,  which 


ELEVATIONS. 


233 


FIG.  18. 


were  round  and  soft,  but  not  tender  on  pressure.     On  bringing 

the  cervix  into  view  with   the   specu- 
lum, these  small  softish  bodies  would 
be    seen    more   distinctly ;    they   were 
of   a    deep    red  color,   of  the   volume 
of    small   peas,   and   without  pedicles. 
It  was  supposed  that  they  were  varices. 
450.  Fig.  19.  In  this  case  there  was 
also  inflammation    of  the  cervix ;    the 
catamenia  were    abundant  and  irregu- 
lar, accompanied  with  leucorrhea  and 
considerable   tumefaction  of   the 
uterus.    The  surface  of  the  cervix 
uteri   was    livid,   and   beset  with 
milliary    vesicles ;    the    os    uteri 
bled  on  pressure,   and  in  the  act 
of  defecation. 

451.  Fig.  20.  Case  of  inflamma- 
tion of  the  cervix  uteri,  present- 
ing the  more  severe  symptoms  of 
the  affection.    The  catamenia  were 
frequent  and  very  abundant,  the 
pains  very  acute.     On  exami- 
nation,  the    cervix   uteri   was 
found  resting  on  the  perineum ; 
the  cervix,  of  a  brownish-red 
color,    was    not    much    larger 
than  when  in  its  natural  state ; 
it  was,  however,  soft,  and  pre- 
sented on  its  anterior  labium, 
two    small,    white,    and    solid 
tumors,  of  the  size  of  a  small 
pea ;   this   part   of  the   uterus 
was  the  seat  of  severe  pain. 
FIG-  20.  452.   Fig.  21.   Inflammation 

of  the  cervix  uteri,  with  hypertrophy.     It  will  be  observed  that 
the  os  is  large  and  transverse,  dividing  the  cervix  into  two  lips 


FIG.  19. 


234 


DISEASES      OF      TV  0  M  E  X 


FIG.  21. 


On  the  anterior  lip  there  is  a 
well-defined  ulcer,  with  uneven 
edges,  extending  into  the  cav- 
ity of  the  cervix.  The  surface 
of  the  cervix  is  seen  covered 
with  granular  elevations. 

453.  Treatment. — In  addi- 
tion to  the  treatment  recom- 
mended for  the  inflammation, 
it  will  be  necessary  in  these 
cases  to  resort  to  the  caustic 
applications  to  destroy  the 
superabundant  growth.  This  may  sometimes  be  done  by  the  use 
of  astringents,  as  the  application  of  Pulverized  Alum  to  the 
cervix,  or  by  the  use  of  the  Sesqui-Carbonate  of  Potassa,  or 
Nitrate  of  Silver.  If  these  should  fail,  we  would  have  to  resort 
to  the  use  of  the  Potassa  Cum.  Calce.,  observing  the  same  pre- 
cautions that  have  been  heretofore  mentioned. 

ULCERATION  OF  THE  CERVIX  UTERI. 

454.  We  have  already  seen  that  inflammation   of  the   cervix 
uteri  may  exist  even  for  years,  without  producing  ulceration ;  this, 
however,  is  the  exception,  and  not  the  rule,  inflammation  of  the 
cervix,  in  a  majority  of  cases,  producing  ulceration  or  erosion. 
Indeed,  the  mucous  membrane  covering  the  cervix,  and  lining  its 
cavity,    especially    that    portion    near    the    os,    appears    to    be 
peculiarly  liable  to  ulceration  as  the  result  of  inflammation. 

455.  Ulceration  of  the  cervix  generally  commences  near  the  os, 
and  from  this  point  it  may  extend  to  the  cavity  of  the  cervix, 
involving  more  or  less  of  it,  in  some  rare  cases  extending  up  it  as 
far  as  the  os  internum,  or  it  may  extend   outward,  involving  a 
greater   or  less   portion  of  the  mucous   membrane   covering  the 
cervix. 

456.  This  ulceration  varies  in  character,  from  the  slight  erosion 
already  described,  and  which  can  with  difficulty  be  distinguished, 
to  the  deep,  perfectly-formed  ulcer.     The  depth  of  these  ulcers 
Varies  from  one   to  six  lines,  though  they  never  present  well- 


ULCE  RATION     OF     THE    CERVIX     UTERI.  235 

defined  edges  to  the  touch,  like  ulcers  in  other  situations.  The 
edges  of  the  ulcer  are  never  indurated,  raised  or  everted,  and  by 
this  single  feature  they  may  be  distinguished  from  syphilitic  or 
scrofulous  ulceration.  In  general  but  one  ulcer  is  found  upon  the 
cervix,  and  this  near  the  os  ;  it  may,  and  frequently  does  extend 
to  the  cavity  of  the  cervix,  and  outwardly  involving  more  or  less 
of  the  surface  of  the  cervix;  sometimes,  however,  several  small 
ulcerations  may  be  observed  around  the  os,  in  addition  to  the 
large  one ;  those  are  supposed  to  be  formed  by  ulcerated  mucous 
follicles.  The  bottom  of  the  ulcer,  in  most  instances,  is  filled  with 
healthy  granulations,  and  covered  more  or  less  with  purulent 
matter.  These  granulations,  according  to  Dr.  Bennet,  may  be 
firm,  of  a  vivid  hue,  scarcely  bleeding  upon  pressure ;  or  they 
may  be  large,  fungous,  livid,  and  bleeding  profusely  at  the 
slightest  touch.  These  fungous  ulcerations  are  generally  con- 
nected with  torpor  of  the  local  circulation.  When  they  are 
present,  the  congestion  of  the  cervix  and  vagina  is  very  great,  of 
a  livid  or  venous  character,  and  the  non-ulcerated  cervix  may 
present  dilated  varicose  veins.  It  is  the  presence  of  these  varicose 
veins  that  has  led  French  writers  to  give  to  ulcerations,  in  which 
they  occur,  the  name  of  varicose  ulcerations.  In  pregnant  women, 
after  the  first  few  months,  ulceration  of  the  cervix  generally 
assumes  this  fungous  form.  Sometimes  the  granulations  of  a 
purely  inflammatory  but  luxuriant  sore,  will  rise  above  the  level 
of  the  surrounding  parts,  and  even  form  small  fleshy  masses, 
which  may  be  partly  brought  away  by  the  finger,  or  which 
separate  spontaneously.  Ulcerations  of  this  description  bleed 
profusely  whenever  they  are  interfered  with ;  sometimes  to  such 
an  extent,  that  on  bringing  them  into  view  with  the  speculum,  the 
blood  partly  fills  the  instrument  as  often  as  it  is  wiped  away. 

457.  The  cavity  of  the  cervix  is  always  more  or  less  affected 
by  ulceration  of  the  cervix  ;  the  ulceration,  as  we  have  already 
seen  in  a  great  majority  of  cases,  commences  near  the  os  ;  the 
lips  of  the  os  swelling,  enlarging,  and  expanding,  open  the 
external  orifice.  The  orifice  is  sometimes  so  enlarged  that  the 
first  joint  of  one  or  two  fingers  may  be  introduced  into  the 
cavity ;  in  slighter  cases,  the  finger  merely  passes  between  its 


236  DISEASES      OF      WOMEN. 

patulous  lips.  Very  frequently  the  ulceration  extends  to  the 
cavity  of  the  cervix,  sometimes  involving  its  entire  dilated 
portion.  It,  however,  rarely  if  ever  extends  to  the  cavity  of 
the  uterus,  the  natural  constriction  at  the  os  internurn  appearing 
to  prove  an  effectual  barrier  to  its  further  progress.  Again,  in 
some  instances,  the  cavity  of  the  cervix  may  be  dilated,  and 
ulceration  be  present  in  it ;  but  the  external  orifice  will  be  nearly 
closed.  In  these  cases,  if  the  os  be  not  opened,  and  the  canal  of 
the  cervix  examined,  the  disease  may  remain  undiscovered  for 
months,  the  treatment  used  to  relieve  the  difficulty  proving  inef- 
fectual. To  dilate  the  os  and  examine  the  cavity  of  the  cervix, 
take  the  Ricord  speculum,  remove  its  loose  blades,  and  introduce 
it  so  that  its  handles  will  project  laterally  toward  the  thigh  of  the 
patient ;  then,  when  its  blades  are  opened,  it  will  separate  the  lips 
of  the  os. 

458.  Ulceration   of  the  cervix  uteri,  in  nearly  every  instance, 
aggravates    the    symptoms   of  inflammation.     Thus,    the   lumbo- 
sacral,    ovarian,    and    hypogastric    pains    will    be    increased   in 
intensity,   the   constitution   will  suffer  more,   and,   therefore,  the 
constitutional  symptoms  will  be   increased.     Sometimes,  though 
rarely,  the  patient  will  have  no  discharge  from  the  vagina,  but,  in 
the   majority  of  instances,  there  will  be  a  continuous  white  dis- 
charge.    Mucus  will  form   a  greater  or  less   proportion  of  this 
discharge,   the  irritation   of   the   mucous  follicles  of  the  cervix 
and   upper  portion   of   the   vagina,   causing  a  greatly  increased 
secretion,  and  the  same  irritation,  extending  to  the  canal  of  the 
cervix,  produces   an  increased  secretion    of  the  peculiar,   thick, 
ropy,  transparent  white  of   egg  mucus,  from    that  canal.     This 
mucus  is  mixed  with  a  larger  or  smaller  quantity  of  purulent 
matter,  thrown  off  by  the  ulcer.     When  the  discharge  is  purely 
purulent,  it  is  generally  thick,  yellow,  and  seldom  very  abundant. 
As  we  have  already  seen,  when  the  granulations  assume  a  fungous 
form,  the  vaginal  secretions  may  be  more   or  less  mixed  with 
blood ;  this  occurs  especially  after  any  exertion  or  severe  exer- 
cise,   or   after   coition,    though   it  may  take  place  at  intervals, 
without  any  appreciable  cause. 

459.  Treatment. — The  general  treatment  in  ulceration  of  the 


ULCERATIOX     OF     THE     CERVIX     UTERI.          237 

cervix  should  be  the  same  as  that  recommended  in  inflammation. 
In  fact,  the  general  and  local  treatment  there  laid  down  will  be 
sufficient  to  overcome  the  mild  cases  of  ulceration.  If,  however, 
the  ulceration  does  not  heal  under  the  use  of  the  local  applica- 
cations  recommended,  and  the  ulcer  presents  a  healthy  appearance, 
we  might  u-se,  in  many  cases,  the  following  injection,  with  much 
benefit : 

H    Hydrastis  Canadensis,  Sss. 

Statice  Limonuin,  Sj 

Chlorate  of  Potassa,  588. 

Aqua  Bulliens,  Oct.  j. 

Let  it  boil  for  fifteen  or  twenty  minutes,  strain  when  cold,  and 
use  a  common-sized  female  syringe  full  twice  a  day.  This  should 
be  followed,  in  about  fifteen  minutes,  by  free  injections  of  cold 
water.  If  it  produces  too  much  irritation,  it  will  be  better  to 
use  it  but  once  a  day,  and  make  the  water  used  after  it  slightly 
acidulous  with  vinegar. 

In  other  cases,  it  will  be  better  to  apply  the  Sesqui-Carbonate 
of  Potassa  to  the  ulcer.  The  way  that  I  use  the  Potassa  is  td 
make  a  saturated  solution  of  it,  and  dip  a  lock  of  raw  cotton  in  it, 
of  sufficient  size  to  cover  the  entire  extent  of  the  ulcer,  sprink- 
ling on  the  cotton  as  much  of  the  dry  Potassa  as  will  adhere. 
This  is  then  introduced  through  the  speculum,  and  applied  to  the 
ulcerated  cervix ;  it  may  be  surrounded  with  the  raw  cotton,  to 
prevent  its  affecting  the  vaginal  walls ;  a  string  may  also  be 
fastened  to  it,  so  that  it  may  be  withdrawn  by  the  patient.  In 
from  half  an  hour  to  an  hour  this  may  be  withdrawn,  and  the 
injections  of  water  and  vinegar  used  after  it.  It  should  be 
repeated  at  intervals  of  two,  three,  or  four  days,  as  the  case 
seems  to  require,  until  cicatrization  is  complete.  In  all  the  cases 
that  have  come  under  my  notice,  I  have  used  this  agent  with 
entire  success.  It  promotes  healthy  granulations  from  the  surface 
of  the  ulcer,  and  if  the  granulations  be  too  large  or  irritable,  it 
breaks  them  down  and  subdues  the  irritability.  Probably  all  who 
have  used  this  agent  have  noticed  its  peculiar  effects  on  the  living 
tissues ;  while  not  so  strong  as  to  endanger  healthy  parts,  even  to 


'238  DISEASES      OF      AYOMEX. 

break  down  healthy  granulations  in  a  wound  or  ulcer,  yet,  it  is 
almost  invariably  effectual  in  removing  fungous  or  callous  growths, 
and  stimulating  healthy  suppuration  or  granulation.  It  not  only 
produces  a  healthy  condition  of  the  ulcer,  but  it  likewise  rapidly 
educes  the  induration  and  hypertrophy  accompanying  it.  I 
recommend  this  agent  thus  strongly,  because  I  know  from  experi- 
ence, that  its  action  will  be  found  much  more  beneficial  than  the 
nitrate  of  silver,  so  commonly  resorted  to  in  this  disease. 

460.  If  the  ulceration  extends  to  the  cavity  of  the  cervix,  the 
caustic  should  be  applied  to  it  in  the  same  manner  already  spoken 
of.     Take  a  lock  of  cotton  of  sufficient  size,  roll  it  into  a  conical 
form,  saturate  it  with  the  solution,  and  introduce  into  the  cavity 
of  the  cervix.     The  application  of  the  potassa  to  the  cavity  of 
the  cervix,  will,  in  some  instances,  produce  severe  pain,  but  this 
always  ceases  in  from  ten  to  thirty  minutes. 

461.  The  nitrate  of  silver  is  the  agent  most  commonly  employed 
in  these  cases ;  it  is  applied  through  a  speculum,  by  means  of  a 
proper  caustic-holder,  or  in  solution,  with  a  camel's-hair  pencil.     It 
is  freely  applied  to  the  surface  of  the  ulcer,  and  to  its  edges;    if 
thus  applied,  it  forms  a  white  film  or  eschar,  about  the  thickness 
of  a  piece  of  drawing-paper ;  this  is  thrown  off  about  the  third 
day.     The  surface  of  the  ulcer  after  the  eschar  is  thrown  off.  is 
generally  found  red,   irritable  and  bleeding;  in   another  day  or 
two,  this  redness  and  tendency  to  bleed  has  disappeared,  and  by 
the  seventh  or  eighth  day,  all  the  benefit  to  be  derived  from  the 
cauterization  is  apparent.     After  this  time,  if  the  caustic  be  not 
reapplied,  the  ulcer  soon  assumes  the  appearance  it  had  before ; 
its  irritability  returns,  as  well  as  the  sympathetic  reaction  on  the 
general   system.      This  caustic  should  be  reapplied   as   often  as 
every  five,  six  or  seven  days,  until  the  ulcer  has  healed. 

462.  In  those  cases  that  resist  the  action  of  the  agents  above- 
named,  it  will  be  necessary  to  resort  to  the  application  of  the 
stronger   caustics,  the  potassa  cum.   calce.,  and  the  potassa  fusa. 
Whether  these  agents  would  be  required,  if  the  sesqui-carbonate 
of  potassa  was  used  in  the  manner  already  described,  I  am  unable 
to   say,   never  having  seen   a  case    that  resisted   its   use.     The 
stronger   caustics   are  used  to  modify  the  vitality  of  the  parts, 


ULCERATION     OF     T1IK     CERVIX     UTERI.  239 

excite  a  healthy  inflammation  and  suppuration,  and  thus  promote 
the  formation  of  healthy  granulations  and  cicatrization.  The 
mode  of  using  these  agents,  has  been  already  described  in  the 
treatment  of  hypertrophy.  The  same  care  should  be  employed 
when  using  them  for  ulceration.  If  these  caustics  are  used  merely 
to  modify  the  vitality  of  the  part,  they  should  not  be  kept  in  con- 
tact with  the  part  but  a  few  seconds  ;  if,  however,  the  intention  is 
to  produce  a  slough,  they  must  be  kept  in  contact  longer.  Accord- 
ing to  Dr.  ]>ennet,  the  eschar  produced  by  potassa  fusa,  does  not 
fall  off  at  any  given  time,  but  melts  away,  as  it  were,  revealing  a 
healthy,  granulating  surface,  from  which  it  has  gradually  been 
thrown  off.  This  gradual  disintegration  of  the  eschar  is  accom- 
plished in  from  five  to  ten  days,  according  to  the  depth  to  which 
the  tissues  have  been  destroyed.  At  about  the  third  day,  if  the 
cauterization  has  been  deep,  the  surrounding  parts  will  be  found 
the  seat  of  considerable  inflammatory  reaction,  and  the  cervix  and 
the  upper  portion  of  the  vagina  will  generally  be  found  consider- 
ably congested  and  inflamed.  The  elimination  of  the  eschar  may 
be  attended  with  hemorrhage,  though  this  may  be  readily  arrested 
with  cold  astringent  vaginal  injections.  In  the  course  of  from 
seven  to  fourteen  days,  the  cervix  and  adjacent  parts  return  to  the 
state  in  which  they  were  before  the  application  of  the  caustic. 
The  ulcer  will  generally  be  found  larger,  the  granulations  are 
more  florid  and  more  developed,  and  appear  endowed  with  more 
vitality.  For  ten  or  fourteen  days  that  follow,  there  is  little  or 
no  change  in  the  ulcerated  surface,  which  continues  to  secrete 
healthy  pus ;  but  about  the  twenty-fifth  day,  from  the  date  of  the 
cauterization,  a  decided  progression  toward  cicatrization  com- 
mences. This  tendency  to  heal  in  the  ulceration,  continues  to  be 
very  marked,  from  about  the  twenty-fifth  to  the  fortieth  day,  when 
it  ceases.  Very  frequently,  the  ulceration  heals  before  the  for- 
tieth day ;  but  if  it  does  not,  the  influence  of  the  strong  potassa 
cauterization  being  exhausted,  it  must  either  be  repeated,  or  the 
treatment  be  carried  on  with  the  milder  caustics,  if  it  is  thought 
that  they  alone  will  suffice.  Severe  cauterization  should  never  be 
resorted  to,  within  less  than  twelve  days  of  the  menstrual  epoch, 
which  it  often  slightly  accelerates. 


240  DISEASES    OF    WOMEN. 

463.  In  using  either  the  nitrate  of  silver,  the   potassa  cum. 
calce.,  or  the  potassa  fusa,  for  ulceration  of  the  cavity  of  the 
cervix,  it  would  always  be  better  to  apply  them  in  solution,  with  a 
camel's-hair  pencil,  in  consequence  of  the  danger  of  breaking  the 
stick  and  leaving  a  portion  of  it  in  the  cervix.     The   application 
of  the  stronger  caustics  to  the  cavity  of  the  cervix  should  also  be 
very  light ;  the  object  not  being  to  produce  a  slough,  or  to  excite 
severe    inflammation,   but   merely   to    modify    the    action    of  the 
ulcerated  surface. 

CORRODING  ULCER  OF  THE  UTERUS. 

464.  This  disease,  fortunately,  is  of  very  rare  occurrence ;  it 
rarely  attacks  females  under  forty  years  of  age,  although  it  has 
been  met  with  in  persons  younger  than  this.     Dr.  Ashwell  defines 
it  to  be  "an  ulcer  of  granular  shape,  commencing  in  the  glandular 
structure  of  the  cervix,  rarely  of  large  size,  but  destroying  life  by 
a  corroding  or  eating  away  of  the  uterus,  even  to  its  fundus,  and 
occasionally  implicating  the  bladder,  vagina,  and  rectum.     There 
is  less  pain  than  in  cancer  of  the  womb,  from  which  it  also  differs 
in  there  being  no  indurated  deposit,  no  immobility,  and  no  fungoid 
growths  in  the  seat  of  the  ulceration.     It  is  malignant,  and  except 
in  the  commencement,  entirely  incurable." 


FIG.  22. — CORRODING  ULCER  OF  THE  UTERUS. 

465.   Prof.  Rokitansky  thinks  that  it  may  be  compared  to  the 
phagedenic  (cancerous)  sore  of  the  skin ;  without  having  a  morbid 


CORRODING     ULCER     OF     THE     UTERUS.  241 

growth  for  its  base,  it  gradually  destroys  the  cervix,  and  even  the 
greater  part  of  the  uterus,  and  may  extend  to  the  rectum  and  the 
bladder.  It  is  an  irregular,  sinuous,  jagged  ulcer,  the  tissues  at 
the  margin  and  the  base  of  which  are  thickened  or  hypertrophied, 
in  consequence  of  a  sluggish  inflammatory  process.  The  base 
presents  a  greenish  and  brownish-green  discoloration,  with  a  slight 
glutinous  and  purulent,  or  a  more  copious  and  watery  secretion. 
There  are  no  granulations,  but  we  find  an  exudation,  and  accord- 
ing to  the  immediate  reliction,  the  tissues  are  converted  into  the 
above-mention-ed  products  of  the  ulcerating  surface." 

466.  Symptoms. — This  disease  may  be  preceded  by  pains  in 
the  pelvis,  a  leucorrheal  discharge,  and  other  symptoms  of  uterine 
disease ;    in  other  cases  reported,  none  of  these  symptoms  were 
manifested   until    the   ulceration   was  fully  developed.     In  some 
cases,  attention  is  directed  to  the  disease  by  a  profuse  hemorrhage 
recurring  at  irregular  intervals,  and  which  is  often  mistaken  for 
a   recurrence    of  the   catamenia.     When   the    ulceration  is   fully 
developed,  a  profuse  discharge  takes  place  from  the  vagina  of  a 
thin,  watery,  and  ichorous  fluid,  which  is  generally  of  an  offensive 
odor.      The   color   of   this  discharge  varies    from    a   light   straw 
color,  to  a  dark  brown ;  sometimes,  though  not  often,  it  becomes 
purulent. 

467.  Dr.  Churchill  says,  "soon  after  this  disease  has  developed, 
we  find  the  patient  complaining  of  weakness,  weight,  and  pain  in 
the  back ;  the  latter  sometimes  extending  to  the  loins,  or  round 
the  lower  part  of  the  abdomen.     The  character  of  pain  is  by  no 
means  uniform  ;  sometimes  it  is  described  as  lacerating,  resembling 
a  knife  running  into  the  back  ;   at  others,  burning  like  a  hot  iron. 
In   a  fewr  of  the  cases  that  I  have  seen,  no  pain  whatever  was 
experienced  from  the  commencement.     The  great  weakness  of  the 
back,  however,  was  present  in  all.     Of  course,  so  grave  an  attack 
can  not  occur  without  severely   affecting  the  constitution.     The 
patient  becomes  emaciated ;    the  appetite  diminishes ;   occasional 
sickness  of  the  stomach;  the  bowels  are  irregular;  the  pulse  is 
quick  and  small ,  the  skin  becomes  dry  and  sallow,  and   a  low 
fever  sets  in.     From  this  time  the  disease  advances  with  variable 
rapidity ;    in  some   cases  it  makes  rapid   progress ;    in  others  it 

16 


242  DISEASES     OF     WOMEN. 

may  continue  for  years  without  extinguishing  life.  As  the  disease 
continues,  the  discharge  is  augmented,  the  fever  increases,  and  the 
patient  loses  all  her  flesh ;  the  features  are  sharpened  and  the  eyeg 
sunken ;  the  skin  dry,  or  perhaps  moist  and  flabby ;  the  appetite 
ceases;  dyspepsia  is  constantly  present;  the  bowels  are  consti- 
pated, and  their  evacuation  causes  severe  pain.  The  distress  of 
the  patient  is  often  increased  by  excoriation  of  the  vulva,  caused 
by  the  acrid  discharge.  Ultimately,  the  patient  sinks  from 
exhaustion,  or  is  carried  off  by  peritonitis,  from  the  extension  of 
ulceration  to  that  cavity,  or  by  hemorrhage.  The  latter  termina- 
tion is,  however,  very  rare." 

468.  Diagnosis. — There  is  no  disease  with  which   this  can  be 
confounded,  if  we  except  cancer  in  its  ulcerative    stage.     These 
two  diseases  may  be  distinguished  by  the  fact,  that  in  corroding 
ulcer  there  is  no  increase  in  the  size  of  the  cervix,  but  the  reverse, 
the  cervix  becoming  smaller  as  the  disease  advances,  from  loss  of 
tissue  ;  this  ulceration  does  not  arise  from  an  indurated  base  like 
cancer,  and  there  is  never  any  fungous  groAvth  in  its  cavity ;  in 
this  disease,  likewise,  we  do  not  find  any  adhesions  or  deposits 
between  the  uterus  and  adjacent  parts,  but  it  retains  its  natural 
mobility. 

469.  Treatment. — In  this  disease,  we  have  a  malady  entirely 
local,  and  not  like  cancer  of  the  uterus,  affecting  adjacent  parts 
by  the  deposition  of  cancerous  material,  nor  affecting  the  adjacent 
lymphatic   glands,  nor   the   system.     It   is   true,  the    system   is 
affected  sympathetically,  and   by  loss  of  fluids,  yet  there  is  no 
specific  infection,  like  there  is  in  carcinoma.     From  these  facts, 
the  disease  should  be  considered  more  amenable  to  treatment  than 
cancer.     Still,  after  it  has  extended  beyond  the  cervix,  the  treat- 
ment will  have  to  be  merely  palliative.    Severe  cauterization  is  the 
only  treatment  that  has  ever  been  found  to  give  permanent  relief. 
Dr.  Churchill  states  that  he  has  used  the  nitric  acid,  chloride  of 
zinc,   caustic   iodine,  etc.,  in  several   cases,  and  though  it  was 
impossible   to   get  the  ulcer  to  heal,  yet  its  progress  could  be 
arrested,  the  hemorrhage  stopped,   the   pain   relieved,    and   the 
discharge   moderated.     In   one  case,  he  supposed  that  life  was 
prolonged  a  long  time  in  consequence  of  their  application. 


C  A  U  L  T  F  L  O  W  K  K     K  X  C  R  K  S  C  E  X  C  E  .  24  3 

470.  As  we  know  that  the  potassa  fusa  exerts   a  much  more 
favorable  influence  in  modifying  the  vitality  of  the  parts,  and  that 
under   its  effects    cicatrization    progresses   much   more   favorably 
than  under  the   use  of   other   caustics,  I   think    that    this    agent 
should  be  preferred  to  any  other.     If  the  disease  is  still  confined 
to  the  cervix,  the  ulcer  should  be  freely  cauterized  with  the  stick 
potassa,  using  the  same  precautions    heretofore  spoken  of  when 
describing  this  agent.      After  the  separation  of   the  slough,   the 
ulcer  should  be  closely  watched,  and  the  stimulation  kept  up  by 
the   occasional    application    of    the    scsqui-carbonate  of   potassa. 
Injections   of   cold   water   would    also   be   useful,    to    remove    the 
discharges  and  prevent  irritation  of  the  vagina  and  vulva.     The 
strong   potassa  cauterization  should  be   repeated  as   soon  as  the 
effect    of  the  first  cauterization  has  passed  off. 

471.  With   this  local  treatment,  such  general  measures  should 
be  employed,  as  would  keep  up  the  strength  of  the  patient,  and 
keep  the  secretions  and  excretions  in  their  normal  condition.     If 
there  be  much  pain  with  the  disease,  narcotics   will  have   to  be 
used  to  give  the   patient  present  relief.     It  would   be   better  to 
commence  with  those  which  do  not  constipate  the  bowels,  as  the 
hyosciamus,  Chloral,  Cannabis  Indica,  etc.     These,  however,   in 
time,  will  have  to  give  place  to  some  of  the  preparations  of  opium. 

In  those  case  in  which  the  ulceration  has  extended  to  the  body 
of  the  uterus,  to  the  rectum  or  bladder,  nothing  can  be  done  for 
the  patient  but  to  palliate  the  symptoms,  and  thus  smooth  her 
pathway  to  the  grave.  The  narcotics  already  mentioned  may  be 
given  to  allay  the  pain.  The  fetor  of  the  discharge,  as  well  as  its 
ichorous  properties,  may  be  modified  b_y  the  use  of  Carbolic  Acid 
and  Glycerine,  of  that  strength  which  gives  most  relief. 

CAULIFLOWER  EXCRESCENCE. 

472.  This  disease,  like  the  one  last  described,  is  not  of  frequent 
occurrence ;  it  may  be  met  with  in  females  of  all  ages,  whether 
married    or    unmarried,    and    without    regard    fco    constitutional 
peculiarities,  habits  or  residence.     Dr.  Ashwell  defines  this  to  be 
"  a  morbid  growth  of  the  os  uteri,  consisting  of  minute  ramifica- 
tions of  arteries,  connected  by  a  fiocculent  tissue,  and  covered 


244  DISEASES    OF    WOMEN. 

with  a  secreting  membrane.  Its  surface  has  somewhat  of  the 
granulated  feel  of  the  broccoli ;  it  bleeds  on  slight  handling,  and 
almost  constantly  pours  forth  a  watery  discharge.  It  varies  in 
size,  is  nearly  painless,  and  proves  its  malignancy  by  returning 
after  removal,  either  by  the  knife,  ligature,  or  caustic."  Mr. 
Paget  considers  the  true  cauliflower  excrescence  to  be  a  variety 
of  the  epithelial  cancer ;  he  says  only  a  part,  however,  of  the 
cases  to  which  this  name  has  been  ascribed,  have  been  epithelial 
cancers ;  of  the  rest,  some  were  medullary  cancers,  and  some, 
perhaps,  simple  non-cancerous,  healthy,  warty,  or  papillary 
growths. 

473.  According  to  Virchow,  this  begins  as  a  simple  papillary 
tumor,   and    at    a   later   period   passes    into    cancroid    (epithelial 
cancer).     At  first  one  sees  only  on  the  surface  papillary  or  villous 
growths,  which  consist  of  very  thick  layers  of  peripheral,  flat  and 
interior    cylindrical    epithelial    cells,  -and    a    very    fine    interior 
cylinder  formed  of  an  extremely  little  connective  tissue  with  large 
vessels.     The  outer  layer  contains  cells  of  all  sizes  and  stages  of 
development ;  some  of  them  forming  great  parent-structures  with 
endogenous    corpuscles.      The    vessels    are,    for    the    most    part, 
collossal,  very  thin  walled  capillaries,  which  form   either  simple 
loops  at  the  apices  of  the  villi,  between  the  epithelial  layers,  or 
toward    the   surface    loops    in    constantly   increasing  number,   or 
lastly  present  a  reticulate  branching.     At  the  beginning  of  the 
disease,  the  villi  are  simple  and  close-pressed,  so  that  the  surface 
appears    only    granulated ;    it    becomes    cauliflower-like    by   the 
branching  of  the  papillae,  which  at  last  grow  out  to  fringes  an  inch 
long,  and  may  present  the  appearance  of  a  hydatid  mole.     After 
the  process  has  existed  for  some  time  on  the  surface,  the  cancroid 
alveoli  begin  to  form  deep  between  the  layers  of  the  muscular  and 
the  connective  tissue  of  the  organ. 

474.  Of  a  specimen  of  the  cauliflower  excrescence  removed  by 
excision  of  the  cervix,  Dr.  Simpson  says : 

"  The  excresence,  after  its  removal,  was  found  to  measure  two 
inches  and  three-quarters  at  its  broadest  part,  and  two  inches  and 
a  quarter  at  its  greatest  depth.  The  thickness  of  it,  where  it 
implicated  the  posterior  lip  of  the  os  uteri,  was  one  and  three- 


CAULIFLOWER     EXCEESCEN  CE. 


245 


eighths  of  an  inch,  but  on  either  side  it  stretched  forward   and 

O  7 

involved  the  angle  between  the  anterior  and  posterior  lips;  thus 
rendering  this  admeasurement  greater  in  its  lateral  parts.  The 
anterior  lip  of  the  os  b  a 

uteri,  which  was  fully 
removed  as  high  as 
the  reflection  of  the 
vagina,  seemed  sound  a 
except  at  the  above 
angles.  The  poste- 
rior surface  of  the 
posterior  lip  was 
densely  and  com- 
pletely covered  by 
the  excrescence  up  to 
the  reflection  upon 
the  vagina.  In  ex-  FIG.  23. — CAULIFLOWER  EXCRESCENCE  OF  Os  UTERI. 

^ieirirr  -rlio  rli«Pi«P/l  aa,  Probe  passed  through  the  Cavity  of  the  Os  and  Cervix  Uteri;  b, 
Anterior  Lip  of  the  Uterus ;  c,  Posterior  Lip ;  dd,  Line  of  Incision  by 

Tiart  I  removed  it  SO  which  the  Cervix  Uteri  was  removed;  e,  Rough  Surface  of  the  Tumor 
attached  to  the  Posterior  Lip. 

high  as  to  bring  away 
all  around,  a  small  portion  of 
the  reflection  itself  of  the  mu- 
cous membrane  of  the  vagina. 
The  surface  of  this  portion  of 
membrane,  as  thus  removed  in 
attachment  to  the  upper  edge 
of  the  excrescence,  appeared 
quite  healthy  on  careful  exami- 
nation of  the  excised  mass,  b" 
The  surface  of  the  tumor  pre- 
sented a  well-marked  small 
granulated  appearance,  with 
deeper  fissures  crossing  it,  and 
giving  it  an  irregular  and  lobu- 

sides      aa>  Under  surface  of  the  Tumor :  bb,  Portions  lacerated 
by  the  Vulsellum. 


FIG.  24. 


lated   appearance. 


of    it   were    considerably   and 

deeply  lacerated  in  various  places  by  the  teeth  of  the  vulsellum. 


246 


DISEASES     OF     WOMEN 


On  rubbing  down  any  small  part  of  the  recent  tumor  bet-ween  the 
finger  and  thumb,  a  kind  of  vascular  or  cellular  frame-work  was 
all  that  was  left  behind.  The  mass,  before  dividing  it,  was 
steeped  in  a  strong  alcoholic  solution  of  Corrosive  Sublimate,  in 
order  to  insure  its  preservation.  On  making  a  section  of  the 
tumor  after  it  had  been  thus  sufficiently  indurated,  it  presents  to 
the  touch  and  sight  an  appearance  greatly  resembling  that  of  the 
brain  when  hardened  by  the  same  menstruum.  A  number  of 
minute  cells  were  scattered  over  the  surface  of  the  section.  On 
slightly  rubbing  any  part  of  the  section,  but  particularly  the  more 
external  part  of  it,  with  the  handle  of  the 
scalpel,  its  apparently  homogeneous  structure 
at  once  broke  up,  and  resolved  itself  into  a 
number  of  very  small,  connected,  grape-like 
granules.  These  same  granules  imparted  to 
the  external  surface  of  the  excrescence  its 
peculiar  minutely  mammillated  structure ;  while 
their  arrangement  into  nodules,  in  consequence 
of  the  divided  and  lobulated  arrangement  of  the 
superficies  of  the  tumor,  gave  to  the  whole  a 
striking  resemblance  to  the  head  of  the  cauli- 
flower. The  accompanying  wood-cuts,  from 
drawings  of  the  tumor  by  Dr.  Patterson,  give 
excellent  representations  of  its  external  form. 
"  On  submitting  some  very  thin  slices  from  the  surface  of  the 
section  of  the  tumor,  to  a  powerful  microscope  in  the  possession 
of  Dr.  Reid,  it  was  seen  to  be  composed  of  a  number  of  cells, 
arranged  in  some  places  in  groups,  in  others  in  irregular  lines. 
These  cells  each  contained  a  large  nucleus,  and  this  nucleus 
inclosed  several  small  nucleoli." 

475.  Symptoms. — The  patient's  attention  is  first  drawn  to  her 
condition  by  a  watery,  inodorous,  and  almost  constant  discharge. 
This  discharge  may  continue  for  weeks,  and  sometimes  it  becomes 
excessive  in  quantity,  wetting  several  napkins  a  day,  and  yet  the 
patient  does  not  become  sufficiently  alarmed  to  apply  for  medical 
advice.  In  the  course,  however,  of  a  few  weeks,  the  discharge 
becomes  tinged  with  blood,  or  considerable  hemorrhage  may  com& 


FIG.  25. 


CAULIFLOWER     E  X  r  R  K  S  CE  X  C  E  .  247 

on  during  or  after  intercourse,  or  during  defecation:  in  cither  of 
these  cases  the  patient  is  generally  alarmed,  and  consults  her 
physician.  As  the  disease  progresses,  this  hemorrhage  becomes 
more  frequent  and  plentiful ;  sometimes  alarming  hemorrhages 
are  brought  on  by  coition  or  defecation,  and  an  examination  will 
often  cause  severe  flooding.  If  an  examination  be  now  made,  a 
tumor  of  larger  or  smaller  size  will  be  found  attached  to  the  os 
uteri,  of  a  soft  and  granulated  feel,  and  bleeding  on  the  slightest 

O  O  C 

pressure.  It  may  be  attached  to  either  lip  of  the  os,  or  involve 
the  entire  cervix;  when  large,  the  upper  part  of  the  vagina  is 
dilated,  either  anteriorly  or  posteriorly,  to  make  room  for  it. 
When  brought  into  view  by  the  speculum  it  is  of  a  bright  flesh-red, 
and  its  granulated  or  fringed  character  will  be  readily  revealed. 
There  is  hardly  ever  any  pain  with  this  disease,  and  an  examina- 
tion with  the  finger  or  speculum  produces  no  uneasiness.  The 
progress  of  the  disease  is  very  variable.  In  some  cases  where 
the  hemorrhage  is  very  frequent  or  profuse,  it  makes  fearful 
inroads  on  the  constitution,  the  appetite  fails,  dyspeptic  symptoms 
appear,  and,  in  some  cases,  general  dropsy  supervenes,  and  the 
patient  is  rapidly  carried  off,  not  by  the  extent  of  the  local 
disease,  but  by  the  loss  of  fluids  consequent  on  it.  In  other 
cases  the  disease  may  continue  for  two  or  three  years,  or  even 
longer,  when  the  patients  die,  worn  out  by  the  constant  drains  on 
the  system  by  the  discharges  and  hemorrhage. 

476.  Diagnosis. — This  tumor  may  be  distinguished  from  polypi, 
and  fibrous  tumors,  by  its  softness,  granular  surface,  and  profuse 
watery  discharge.     From  cancer,  by  the  discharge,  which  is  never 
fetid,  as  in  cancer,  by  there    being  no  pain,  arid  by  the  distinct- 
ness, mobility,  and  softness  of  the  growth,  and  by  the  peculiarity 
of  its  origin  from  the  os. 

477.  Prognosis. — There  can  be  no  doubt   but   that   this  is  a 
dangerous    disease ;    still,    if    seen    at    its    commencement,    and 
properly   treated,  a  favorable    result    may    be    looked    for.     Dr. 
Simpson's  patient  recovered  after  excision  of  the  cervix,  and  the 
disease  did  not  recur.     Colombat  reports  a  case  of  this1  disease, 
treated   in   the    same    manner,  and    there  was   no   return  of  it 
Boivin  and    Duges  report  a  case  cured.     Dr.  Montgomery  one 


248  DISEASES     OF     WOMEN. 

Dr.  Churchill  reports  a  case  treated  by  deep  cauterization ;  the 
patient  was  well  two  years  afterward. 

478.  Treatment. — Two  methods  of  treatment  are  presented  to 
the   practitioner  as  giving   a  probability  of   success ;    these  are, 
removal    of  the    tumor  by  cauterization,  or  by  excision    of  the 
cervix  uteri. 

Of  these  two  methods  of  treatment,  Eclectics  would  choose 
cauterization,  from  the  great  success  which  has  followed  its 
employment  in  their  hands,  in  the  removal  of  malignant  growths. 
Cauterization,  however,  to  be  effectual,  should  be  deep  enough  to 
destroy  the  base  from  which  the  tumor  springs,  as  we  have  seen 
that  the  cervix  at  this  point  is  generally  infiltrated  with  a  cancer- 
ous deposit,  which  will  rapidly  reproduce  the  morbid  growth.  Of 
the  escharotics  we  will  have  our  choice  of  three,  the  potassa  fusa, 
chloride  of  zinc,  and  arsenious  acid.  The  first  has  been  fully  de- 
scribed already,  the  second  is  very  effective  if  skillfully  used,  and 
the  last  is  especially  recommended  because  it  is  attended  with  less 
pain.  If  we  use  the  chloride  of  zinc,  we  make  a  paste  of  equal 
parts  of  this  and  gum  Arabic,  adding  a  small  portion  of  Sangui- 
naria.  It  should  be  thoroughly  applied  and  rapidly  pushed  to 
the  complete  extirpation  of  the  growth,  the  vagina  being  pro- 
tected by  the  use  of  lint  wetted  with  glycerine.  The  arsenious 
acid  is  used  with  a  paste  of  iron,  as  directed  under  the  head  of 
cancer  of  the  uterus,  and  of  the  strength  deemed  necessary  in  the 
case.  If  the  parts  are  not  irritable,  and  the  growth  not  rapid,  it 
may  be  weak  and  painless. 

479.  Excision  of  the   Cervix    Uteri  has  been  frequently  per- 
formed for  different  diseases,  and  with  variable  results.     "  The 
mortality  of  the  operation  itself  is  about  one  in  six  or  seven." 
Of  all  the  methods  of  operating,  Dr.  Simpson's  is  the  simplest, 
and  on  this  account  preferable.     The  patient  is  placed  upon  the 
face,  the   body  being   situated  across    the   bed,   and   the   lower 
extremities  hanging  over  it,  as  in  the  operation  for  hemorrhoids. 
The  operator  is  thus  enabled  to  make  the  incision,  through  the 
cervix  uteri  from  behind  forward,  and  thus  avoid  wounding  the 
peritoneum,  which  extends  down  much  further  behind   than   in 
front.     A  strong  pair  of  vulsellum-forceps  is  then  introduced  into 
the  vagina,   and   attached   to    the  cervix.      This   may  be    done 


CAULIFLOWER     EXCRESCENCE.  249 

through  a  speculum,  if  the  cervix  is  not  much  enlarged  ;  if  it  is 
enlarged,  the  vulsellum  will  have  to  be  guided  and  attached  with 
the  other  hand.  Having  fixed  the  vulscllurn,  the  cervix  should  be 
gradually  and  cautiously  drawn  down,  until  it  appears  so  far 
beyond  the  vulva  as  to  allow  of  the  excision  above  the  morbid 
growth.  As  the  uterus  retracts  strongly  as  the  incision  is  made, 
the  line  of  the  incision  is  rendered  uneven  and  confused.  To 
remedy  this  defect,  Dr.  Simpson  thinks  that  it  would  be  prefer- 
able to  use  a  pair  of  large,  curved,  blunt-pointed  scissors.  By 
this  means  we  would  be  enabled  to  surround  and  embrace  the 
whole  cervix  at  once,  and  having  cautiously  and  carefully  adjusted 
their  edges  to  the  very  points  which  we  wish  to  divide,  and  thus 
calculated  by  this  preliminary  step  the  exact  limits  of  the  incis- 
ion ;  we  may  then  immediately  complete  the  amputation  of  the 
part  by  one  or  two  strong  and  rapid  strokes  of  the  instrument. 
As  soon  as  the  excision  is  completed,  the  uterus  immediately 
ascends  to  its  natural  position.  Serious  hemorrhage  very  rarely 
occurs  after  this  operation ;  when  it  does,  it  may  be  checked  by 
plugging  the  vagina.  Such  symptoms  as  may  arise  after  this 
operation,  should  be  treated  on  general  principles.  The  success 
attending  it  will  depend  upon  whether  the  entire  morbid  growth 
was  removed ;  for  if  but  a  single  cell  remains,  it  will  probably  be 
reproduced. 

CANCER  OF  THE  UTERUS. 

480.  This  is  one  of  the  most  fatal  and  distressing  maladies  to 
•which  the  female  is  liable  ;  it  is  the  most  irresistible  in  its 
progress,  and  the  least  amenable  to  treatment,  without  it  is  seen 
in  its  earlier  stages.  Females  of  any  age  are  liable  to  it,  though 
it  more  'commonly  occurs  after  child-bearing,  and  about  the  time 
of  the  cessation  of  the  menses.  In  four  hundred  and  nine  cases 
of  cancer  of  the  uterus  referred  to  by  Boivin  and  Duges,  they 
occurred  in  the  following  ratio  : 

Under  twenty  years  of  age,         .         .         .         12 

From  twenty  to  thirty,        ....         83 

"     thirty  to  forty,  ....       102 

"     forty  to  forty-five,     .         .         .         .106 


250  DISEASES     OF     WOMEN. 

From  forty-five  to  fifty,       ....         95 

"     fifty  to  sixty, 7 

"     sixty  to  seventy-one,  ...  4 

Total,         .         .         .         .409 

481.  According    to    that    close    observer,    Prof.    Rokitansky, 
"  Cancer  of    the  uterus  always   attacks    the    cervix  in  the  first 
instance,  and    especially    that    portion    which   projects    into    the 
vagina  ;  the  primary  occurrence  of  carcinoma  at  the  fundus  uteri 
is  so  rare,  that  the  above  observation  may  be  considered  as  an 
absolute  rule.     It  is  contrasted,  in  this  respect,  with  fibroid  and 
tubercular  disease  of  the  uterus,  and  it  presents  a  similar   con- 
trast in  reference  to  its  extension  and  ulcerative  destruction. 

482.  "  Opportunities  very  rarely  present  themselves  for  inves- 
tigating the  early  stages  of  cancer  in  the  dead  subject;  according 
to  a  few  observations,  carcinoma,  when  closely  examined,  appears 
to  consist  of  dense,  whitish,   retiform   fibers,  differing  from  the 
normal  texture  of  the  vaginal  portion  of  the  uterus  in  which  they 
are    found,   and  in    their  very  minute   meshes,  a   pale,  reddish- 
yellow  or  grayish  translucent  substance  is  deposited.     This  mor- 
bid growth  is  inserted  into  the  uterine  tissue,  without  well-marked 
boundaries  ;  it  occupies  a  various  extent,  and  from  accumulating 
at  certain  points,  gives  rise  to  the  irregular  nodulated  character 
and  the  wTell-known  induration  which  accompanies  the  enlarge- 
ment of  the  cervix. 

483.  "  Medullary  cancer,  in  the  first  instance,  appears  as  an 
infiltration  of  a  white  lardaceo-cartilaginous   or   lax,  enceplialoid 
matter,  in   which  the  uterine  fiber  disappears.     As   the    deposit 
increases,  the  vaginal  portion  of  the  cervix  assumes  an  uneven 
nodulated  character,  and  appears  hard  and  elastic  to  th'e  touch. 
Cancer  of  the  uterus  very  rarely  presents  itself  in  the  shape  of 
isolated  globular  growths.     As  the  cancerous  degeneration  pro- 
ceeds,   and    especially    on    the    commencement    of  the  stage  of 
metamorphosis,  with  its   consequent  new  formations,  particularly 
if  they  belong  to  the  medullary  variety,  the  lower  segment  of  the 
uterus  undergoes  a  very  considerable  and  rapid  enlargement ;  at 
last,  we  find  a  callous,  loose,  spongy  ulcer,  developed  in  the  usual 


CANCER   OF    THE    UTERUS. 


251 


manner,  which  discharges  a  very  fetid,  greenish-brown,  sanious 
and  sanguineous  fluid,  and,  as  it  extends,  generally  causes  a 
progressive  infiltration  of  cancerous  matter.  The  tumefaction  of 
the  cervix  and  fungoid  excrescences  not  unfrequently  close  up 
the  orifice,  and  the  consequent  enlargement  of  the  womb  will  be 
the  larger,  the  more  copious  the  secretion  of  mucus. 

484.  "  Cancerous  degeneration  of  the  uterus  is,  generally,  in  a 
very  remarkable  and  distinct  manner,  confined  to  the  vaginal 
portion  ;  still,  there  are  frequent  exceptions  to  this  rule,  as  the 
disorganization  is  sometimes  found  to  extend,  with  great  rapidity, 
to  the  body,  and  even  to  the  fundus  of  the  uterus  ;  this  is  par- 
ticularly the  case,  if  the  os  tincse  has  already  been  attacked  by 
ulceration.  The  disease  may  spread  downward,  and  involve  the 
vagina,  thus  establishing  vaginal  cancer.  It  may  extend  in  other 


FIG.  26. — CANCEROUS  ULCERATION  OF  THE  UTERUS,  INVOLVING  THE  RECTUM  AND 

BLADDER. 

directions,  and  thus  give  rise  to  cancerous  degeneration  of  the 
rectum,  the  bladder,  the  pelvic,  cellular,  and  adipose  tissue,  and 


252  DISEASES     OF     WOMEX. 

the  peritoneum;  the  uterus  thus  becomes  fixed  in  the  pelvis,  and, 
at  last,  we  find  the  peritoneum  attacked,  cancerous  growths  being 
formed  upon  it  and  its  tissue,  or  perforating  it,  especially  in  the 
shape  of  medullary  masses. 

485.  "  Cancerous  ulceration  spreads  in  the  same  direction  ;  in 
rare  cases  we  find  the  greater  part  of  the  uterus,  and  even  its 
fundus  destroyed.     The  destructive  process,  when  attacking  the 
vagina,  sometimes  predominates  on  the  anterior,  sometimes  on  the 
posterior   surface ;  sometimes  it   attacks   both   equally,  and  may 
extend  downward  almost  to  the  external  orifice.     It  also  involves 
the  degenerated  parieties  of  the  rectum  and   of  the  bladder,  and 
generally    produces    extensive    communications    between    their 
cavities  and  the  original  cancerous  sinus.     It  finally  extends,  in 
the    shape    of    sinous    passages,    through    the    remainder  of   the 
cancerous  mass  that  fills  the  pelvic  cavity,  to  the  pelvic  bones. 
In  this  manner  a  large  cavity,  with  fungoid  parieties,  is  at  last 
established,   which   occupies   a  greater  part    of   the    uterus    and 
vagina,  and  opens  into  the  cavities  of  the  rectum  and  the  bladder ; 
above,  it  is  closed  in  by  the  fundus  uteri  and  the  adherent  rectum 
and  cervix  vaginae,  as  also  by  the  caecum  and  small  intestine, 
which  are  agglutinated  to  these  parts,  and  at  last  it  penetrates 
into  the  cavity  of  the  peritoneum   or  the  intestines.     The  con- 
tents   of   the    cavity  are  cancerous  ichor   mixed  up  with  fecal 
matter,  urine,  and  gangrenous  tissue. 

486.  "  Uterine  cancer  is,  in  most  cases,  a  primary  disease,  and 
generally  remains  so  for  a  long  time,  if  not  throughout  the  sole 
carcinomatous  affection  of  the  organism.     However,  it  is  some- 
times  developed  concurrently  with,  or  consecutively  to,  mammary 
and  ovarian  cancer ;  or,  it  is  accompanied  by  degeneration  of  the 
adjoining  tissues  above-mentioned,  and  of  the  lymphatic  glands, 
which  must  be  explained  upon  the  theory  of  propagation  by  con- 
tact; or  it  is  associated  with  cancer  of  the  peritoneum,  of  the 
liver,  stomach,  and  the  breasts,  with  cancer  of  the  bones,  with 
mollites  ossium,  ovarian  cancer,  and  universal  cancerous  deposit, 
as  a  consequence  of  the  resulting  cancerous  dyscrasia." 

487.  Symptoms. — In  the  first  stages  of  this  disease,  the  symp- 
toms are   so    slight  as   to  scarcely   arouse  the   attention  of  the 


CANCER     OF    THE    UTERUS.  253 

patient ;  in  fact,  in  many  cases  the  disease  makes  great  progress 
before  she  considers  that  there  is  sufficient  cause  to  consult  a 
physician.  The  earliest  symptoms  consist  in  the  derangements 
of  the  catamenja,  if  the  disease  occurs  before  the  cessation  of 
this  discharge  ;  thus,  the  menses  may  appear  more  frequently,  as 
often  as  every  two  or  three  weeks,  or  their  appearance  may  be 
retarded.  The  menstrual  secretion  is  generally  much  increased 
in  quantity,  though  it  may  in  some  cases  be  decreased  or  even 
suppressed.  There  is  nearly  always  present,  in  the  forming 
stage  of  cancer,  a  leucorrheal  discharge,  of  a  white  or  yellow 
appearance  ;  this  may  be  profuse,  but  it  is  generally  small  in 
quantity,  without  the  patient  has  had  a  long-continued  discharge 
of  this  kind  ;  this  discharge"  may  be  continuous  or  intermitting. 
Previous  to,  or  immediately  after  the  catamenial  period,  this  dis- 
charge may  be  tinged  or  streaked  with  blood,  or  after  any  local 
excitation,  as  coitus,  violent  emotions,  severe  exercise,  etc. 

488.  As  the  disease  progresses,  the  patient  will  feel  a  constant 
dull  aching  pain  in  the  small  of  the  back,  attended  by  a  Aveakness 
at  that  point.     This  pain    may  extend  down  the  course  of  the 
sciatic  nerve,  presenting  all  the  symptoms  of  sciatica ;  or  it  may 
extend  down  to  the  perineum,  or  down  the  inside  of  the  thighs. 
There  wTill  also  be  ovarian  pain  present ;  it  may  be   located   in 
either,  or  in  both  ovarian  regions.     The  hypogastric  pain,  or  the 
pain   in   the  lower   part  of  the  hypogastric  region   immediately 
above  the  pubis,  is  not  generally  present,  until  the  stage  of  ulcera- 
tion  is  manifested.     With  these  pains,  which  are  generally  inter- 
mittent,  and  scarcely  ever   severe,   the  patient  feels  a  sense  of 
weight  in  the  pelvis,  an  uneasy  tenderness,  and  sometimes  slight 
pains,   especially    during    the  menstrual  period,   or    after    severe 
physical  efforts. 

489.  As  the  disease  becomes  confirmed,  and  ulceration  com- 
mences, all  the  above  symptoms  become  aggravated.     The  lunibo- 
sacral,    ovarian   and  hypogastric   pains    become    aggravated,  the 
pains  in  the  course  of  the  sciatic  nerves,  in  the  perineum,  and 
down  the  inside  of  the   thighs,   if  present,  become  very  severe. 
In  the  majority  of  cases,    the  uterine    pains   now   become   very 
severe.     They  are   described  by  some   as  lancinating,  as  though 


254  DISEASES     OF    WOMEX. 

knives  were  plunged  into  the  body;  by  others,  as  burning,  as 
though  a  coal  or  hot  iron  was  applied  to  the  uterus.  These  pains 
though  continuous,  are  greatly  aggravated  at  times,  when  they 
extend  to  the  back,  to  the  ovaries,  down  the  sciatic  and  crural 
nerves;  in  fact,  follow  the  course  of  all  the  nerves  that  pass  out 
of  the  pelvis.  In  some  few  cases,  there  will  be  little,  if  any  pain 
present.  A  very  marked  symptom  of  cancer  of  the  uterus  is  a 
severe  and  circumscribed  pain  about  the  rectum  and  anus,  simu- 
lating very  much  a  severe  attack  of  piles ;  this  pain  is  almost 
invariably  increased  when  the  patient  goes  to  stool. 

490.  The   severe   suffering,   and  the    profuse    discharges    that 
sometimes  occur,  soon   affect  the  general  health  of  the  patient; 
her    appetite    becomes    poor,   marked    symptoms    of    indigestion 
develop  themselves,  the  bowels  are  irregular,  sometimes  consti- 
pated, at  others,  there   is  a  diarrhea,  or  these  alternately.     The 
patient  though  still  retaining  her  fullness  of  habit,  has  a  blanched 
and   colorless   appearance,  or,  as   is  most  generally  the   case,  a 
peculiar  waxy,  yellowish-white  color.     By  degrees,  the  patient  is 
gradually  exhausted  and  debilitated.     The  digestion  becomes  more 
deranged;  she  is  troubled  with  flatulence,   vomitings,  and  fever. 
These  symptoms  mark  the  close  of  the  disease ;  for  under  these 
intense  sufferings  the  patient  rapidly  sinks. 

491.  Discharges. — Up  to  the  commencement  of  ulceration,  the 
discharges  are  not  changed  in  character,  though  they  are  usually 
augmented  in  quantity ;  sometimes,  however,  they  are  streaked 
with  blood  at  times.     As  soon,  however,  as  ulceration  has  com- 
menced, the  discharges  are  entirely  changed  in  character,  though 
they  are  usually  augmented  in  quantity ;  its  color  varies  from  a 
dirty-white  to  a  dark  brown,  green,  or  black,  and  its  odor  becomes 
almost  in  supportably  fetid,  so  much  as  to  constitute  a  great  source 
of  suffering  to  the  patient.     Sometimes  it  becomes  very  ichorous, 
excoriating  the  parts  over  which  it  flows,  producing   an  erythe- 
matic   inflammation   of    the    vulva,   extending  to   the   anus,   and 
sometimes  down  the  thighs.     If  the  ulceration  involves  the  blad- 
der or  rectum,  opening  into  their  cavities,  there  -will  be  a  constant 
and  involuntary  escape  of  urine,  and  of  fecal  matter  and  flatus 


CANCER     OF     THE     UTERUS.  255 

In  this  case,  the  condition  of  the  patient  is  truly  pitiful,  and  death 
becomes  to  her  a  welcome  visitor. 

492.  Upon  making  an  examination  in  the  forming  stages  of 
this  disease,  the   cervix  will  be  found  somewhat  enlarged,  indu- 
rated, and  presenting  a  nodulated  character.     The  os  uteri  will  be 
more  or  less  open,  and  its  edges  will  feel  indurated  and  hard. 
The  color  of  the  cervix  is  changed  in  the   stage  of  deposition; 
instead  of  presenting  a  pale-rose  red,  its  natural  color,  it  becomes 
of  a  dark  red  or  purplish  color.     The  cervix  uteri  will  not  present 
the  same  degree  of  moisture   as  in  health,  but  will  feel  dry  and 
rough.     As  the  disease  continues,  the  induration  will  be  found  to 
extend,  the  uterus  loses  its  mobility,  and  gradually  increases  in 
size,  sometimes  to  such  an  extent  that  it  can  be  felt  above  the 
pubis. 

493.  When   ulceration    has    taken   place,  an   examination  will 
cause   great  pain.     The   ulcerated   surface  will  be   found  rough, 
unequal  and  tender  on  pressure,  and  the  finger,  when  it  is  with- 
drawn, is  covered  with  a  fetid  sanies,  and  occasionally  tinged  with 
blood.     In  some  cases  the  ulceration  Avill  be  deep,  and  filled  with 
a  fungous  substance  projecting  beyond  the  edges  of  the  ulcer. 
The  ulcerated  surface  has  a  grayish  color,  and  its  edges  are  of 
unequal   elevation,   and  very  uneven    and   ragged;    the    fungous 
growth  from  the  ulcer  is  generally  of  a  purplish  or  dusky  red 
color. 

494.  Diagnosis. — In  the  first  stages  of  cancer  of  the  cervix 
uteri,    it    will   be    very  hard    to    distinguish   it   from    induration 
following    inflammation.      Dr.    Bennet    states    that   inflammatory 
induration  "is  the  disease  to  which  most  authors  and  practitioners 
give  the  name  of  incipient  cancer."     He  says :   "  I  must  again 
repeat,  that  my  own  experience,  as  well  as  the  analysis  of  that  of 
others,  leads  me  to  the  conclusion  that  cancerous  growths  of  the 
uterus,  in  the  incipient  or  non-ulcerated  stage  of  their  develop- 
ment, are  always,  or  nearly  always  indolent,  and  give  rise  to  no 
symptoms  sufficiently  decided  to  induce  patients  to  complain,  or 
to  seek  for  advice ;  and  thus  we  can  explain  how  the  disease,  in 
its  incipient  stage,  does  not  come  under  the  notice  of  the  practi- 
tioner."    He  also  says  :  "  It  is  more  than  probable  that  cancer  of 


256  DISEASES    OF    WOMEN. 

the  cervix  uteri,  instead  of  being  very  slow  in  its  development, 
and  remaining  for  years  in  the  first  or  non-ulcerated  stage,  is,  on 
the  contrary,  very  rapid  in  its  growth  and  progress,  especially  in 
women  who  still  menstruate." 

495.  Dr.  Bennet  states  distinctly  that  cancer  rarely,  if  ever, 
arises  from,  or  is  caused  by,  inflammation  of  the  cervix.     How, 
then,  are  we  to  account  for  the  numerous  cases  of  non-ulcerated 
disease  of  the  cervix,  which,  after  a  longer  or  shorter  time,  have 
become    perfectly    developed,   ulcerated    cancers,   destroying    the 
uterus,  rectum,  vagina  and  bladder  ?     Inflammatory  induration  of 
the  cervix  uteri  is  likewise  a  secondary  process,  which  has  to  be 
preceded  by  inflammation,  and  all   its  attendant  symptoms,  and, 
according  to  Dr.  Bennet,  in  the  most  of  cases,  by  ulceration ;  while 
the  induration  of  the  first  stage  of  carcinoma  uteri  will  be  found, 
in  the  most  of  cases,  not  to  have  been  preceded  by  the  symptoms 
named  as  diagnostic  of  inflammation  and  ulceration  of  the  cervix 
uteri.     It  is  true  that  similar  symptoms  are  developed  in  the  non- 
ulcerated  stage  of  cancer,  but  they  never  precede  the  induration. 

496.  We  would  then  distinguish  the  diseases  by  the  fact,  that 
inflammatory  induration  is  always  preceded  by  morbid  symptoms 
of  inflammation  of  the  cervix,  by  the  purulent  discharge  which  is 
the  pathognomonic  symptom  of  that  disease,  and  its  stationary 
character,  not  generally  increasing  in  size,  and  never  involving 
adjacent  structures,  or  causing  immobility  of  the  womb. 

In  the  ulcerative  stage  we  have  to  distinguish  it  from  corroding 
ulcer,  and  venereal  ulceration.  We  distinguish  it  from  corroding 
ulcer,  by  the  immobility  of  the  uterus,  and  by  the  fetid  character 
of  the  discharge.  From  venereal  ulceration,  by  the  morbid 
deposition,  and  immobility  of  the  uterus,  and  by  the  depth  and 
irregularity  of  the  ulceration ;  venereal  ulcers  being  generally 
smooth  and  even,  no  fungous  growths  attending  them,  and  the 
pain  present  is  neither  so  constant  nor  acute.  There  are  no  other 
diseases  of  the  uterus  with  which  ulcerated  cancer  could  be 
confounded,  unless  we  except  a  case  reported,  in  which  an  intra- 
uterine  polypus  ulcerated,  and  there  was  a  constant  fetid  discharge 
for  more  than  two  years ;  this  case  was  decided  to  be  cancer  by 
several  eminent  practitioners. 


CANCER     OF     THE     UTERUS.  257 

497.  Prognosis. — This,    probably,    is    one    of    the    most    fatal 
diseases  to  which  the  female  is  subject,  yet,  if  seen  in  an  early 
stage  and  properly  treated,  it  may  be  cured.     If  the  disease  is 
still  confined  to  the  cervix,  our  prognosis  should  not  be  unfavor- 
able ;  but,  if  it  has  extended  beyond  this,  not  much  can  be  hoped 
for,  so  far  as  a  radical  cure  of  the  affection  is  concerned ;  we  may 
however,  greatly  alleviate  the  suffering  of  the  patient,  and  prolong 
her  life. 

498.  Treatment. — When  cancer  of  the  uterus  is  confined  to  the 
cervix,  we  may  entertain  strong  hopes  of  being  able  to  remove  it 
by  local   applications.     I  need  hardly   mention   that  I   consider 
excision  of  the  cervix,  in  these  cases,  bad  treatment, — in  but  verv 
few   cases    in    which    it    has    been    resorted   to,  has    the    patient 
recovered, while  the  malignant  character  of  the  disease,  in   these 
few,  has  been  disputed.     The  removal  of  the  disease,  however,  by 
caustic,  has  been  so  often  accomplished,  that  very  few  at  this  day 
will  dispute  the  fact,  that  cancer  of  the  uterus  has  been  removed 
by  this  means. 

499.  The  caustics  that  may  be  most  successfully  employed  in 
these   cases  are  the  potassa  fusa,  chloride  of  zinc,  and  arsenious 
acid.     The  last  is  preferred  b}-  some  because  its  operation  is  quite 
painless. 

In  using  the  potassa.  the  patient  should  be  placed  upon  her 
back,  in  the  usual  position  •  for  making  a  vaginal  examination, 
The  patient  should  then  be  placed  under  the  influence  of  chloro- 
form, as  this  not  only  prevents  pain,  and  the  severe  shock  upon 
the  system  consequent  on  the  severity  of  the  cauterization,  and 
thus  greatly  conduces  to  subsequent  recovery,  but  it  likewise 
places  the  patient  completely  under  the  command  of  the  operator. 
A  large  glass,  or  Ricord  speculum,  should  then  be  introduced,  and 
the  cervix  brought  fairly  in  the  center  of  it.  Cotton,  saturated 
in  a  solution  of  vinegar  and  water  should  then  be  introduced 
around  the  cervix,  carefully  isolating  it  from  other  parts,  that  they 
may  not  be  injured  by  the  caustic ;  it  would  be  well  if  the  Eicord 
speculum  is  used,  to  introduce  the  cotton  between  the  lower  bladea 
of  the  instrument.  Having  the  parts  thus  arranged,  the  stick 
potassa  should  be  applied,  by  means  of  a  proper  caustic-holder, 
17 


258  DISEASES     OF     WOMEN. 

to  the  entire  indurated  portion  of  the  cervix.  The  potassa  should 
be  firmly  applied,  and  continued  until  the  entire  cancerous 
structure  is  removed ;  this  will  take  from  ten  to  thirty  minutes, 
according  to  the  extent  of  the  growth.  The  point  to  be  recollected 
is,  that  if  the  entire  indurated  mass  is  not  removed,  the  malignant 
growth  will  be  reproduced,  and  there  is  no  more  danger  from  a 
thorough  cauteriz-ation  at  once,  than  if  it  has  to  be  repeated  five 
or  six  times  to  accomplish  the  same  purpose.  As  soon  as  the 
cauterization  has  been  effected,  the  vagina  should  be  well  syringed 
out  with  vinegar  and  water  through  the  speculum,  and  when  this 
and  the  cotton  surrounding  the  cervix  is  withdrawn,  the  vaginal 
injections  should  be  repeated,  and  continued  at  short  intervals 
until  the  pain  ceases.  The  slough,  formed  by  the  potassa,  will 
separate  in  from  ten  to  fifteen  days,  according  to  the  depth  of  the 
cauterization.  At  this  time,  a  careful  examination  of  the  parts 
should  be  made,  and  if  any  indurated  portions  remain,  the 
cauterization  should  be  repeated.  The  ulcer  left  after  cauteriza- 
tion, will  have  to  be  watched  until  the  cicatrization  is  completed, 
keeping  down  any  tendency  to  morbid  growth  or  induration,  by 
the  occasional  application  of  the  potassa,  or  chloride  of  zinc 
paste,  described  below. 

500.  This  cauterization  will  be  followed  in  the  most  of  cases 
by  considerable  inflammation.     This  may  be  counteracted  by  the 
application  of  hot  fomentations  of  hops,  or    stramonium  leaves, 
above  the  pubis,  and  over  the  vulva,  with  the  frequent  use  of 
warm  vaginal  injections  of  water,  or  a  decoction  of  stramonium. 
These  measures  may  be  aided  \>y  the  administration  of  the  seda 
tives  in  the  usual  doses,  and  also  by  the  hypodermic  injection  of 
morphia. 

Instead  of  this,  I  have  sometimes  given  very  marked  relief  by 
the  use  of  small  doses  of  Nux  Vomica  and  Pulsatilla,  especially 
when  there  is  abdominal  pain  and  tenderness. 

501.  The  chloride  of  zinc  may  be  used  either  run  into  sticks 
and  applied  in  the  same  manner  as  the  potassa,  or  formed  into  a 
paste.    The  pure  chloride  of  zinc  if  run  into  sticks,  deliquesces  so 
rapidly,  that  it  can  not  be  well  applied;  an  impure  article,  how- 


CAXCEK     OF     THE     UTERUS.  259 

ever,  is  sometimes  made  in  this  form,  "which  answers  the  purpose 
admirably.  The  zinc  paste  may  be  made  by  taking  the  pure 
chloride  in  crystals,  and  letting  it  stand  uncorked,  until  it  has 
deliquesced;  we  then  have  a  pure  saturated  solution;  this  may 
then  be  mixed  with  sufficient  pulverized  hydrastis  eanadensis  to 
form  a  paste.  In  using  this  paste,  it  is  spread  on  a  strip  of 
leather  of  sufficient  size  to  cover  the  diseased  part.  In  using  the 
chloride  of  zinc,  the  same  precautions  should  be  used  to  protect 
the  adjoining  structures,  but  instead  of  the  vinegar  and  water,  a 
solution  of  carbonate  of  soda  should  be  used.  In  usin<;  the  arse- 
nic, make  a  paste  by  throwing  the  hydrated  sesqui- oxide  of  iron 
on  a  filter  paper  until  it  attains  the  proper  consistence,  and  to  this 
add  the  arseuiotis  acid  in  the  proportion  of  oj.  to  o'j-  to  the  5J. 
The  vagina  being  protected  as  before,  the  ointment  is  introduced 
on  pledgets  of  lint,  crowding  it  into  every  cavity,  and  making'  its 
application  as  thorough  as  possible.  It  may  remain  for  one  or 
two  hours,  the  woman  being  in  a  recumbent  position,  and  it  is 
repeated  every  day  until  the  growth  is  thoroughly  destroyed,  and 
can  be  removed  with  the  forceps.  The  ulcer  may  then  be  dressed 
with  powdered  sulphate  of  iron. 

502.  Where  the  disease  has  extended  to,  or  commenced  in  the 
cavity  of  the  uterus,  the  chance  of  saving  the  patient  is  very 
slight.  The  following  treatment,  however,  which  I  copy  from 
the  Eclectic  Surgery  (page  195),  is  said  to  have  proved  successful. 

"  Your  first  local  measure  should  be  the  injection  of  simple 
warm  water  into  the  vagina  and  cavity  of  the  uterus.  The  parts 
are  sometimes  so  very  sensitive,  that  even  this  will  give  the  patient 
considerable  pain.  Were  you,  in  such  a  case,  to  inject  ever  so 
weak  an  alkali,  or  even  soap  and  water,  it  might  excite  dangerous 
inflammation. 

"  Continue  the  warm  water  till  it  occasions  no  pain,  then  begin 
with  weak  soap-suds,  increasing  its  strength  as  the  patient  can 
bear;  in  a  few  days,  you  will  probably  be  able  to  add  a  little 
mild  caustic.  Increase  the  quantity  till  you  can  use  a  saturated 
solution.  All  these  lotions  must  be  thrown  into  the  womb,  by 
means  of  a  catheter. 

"  Directions  for  making  these  uterine  injections  may  not  be 
unnecessary.  Place  a  finger  of  one  hand  on  the  os  uteri;  and 


260  DISEASES     OF     WOMEN. 

with  the  other  hand  direct  the  catheter  along  the  finger  that  kj  on 
the  os,  till  it  also  comes  in  contact  with  the  uterus.  Slip  the 
finger  a  little  aside,  and  the  instrument  will  generally  pass  in  * 
if  not,  turn  it  round  and  round  awhile,  pressing  gently,  till  it 
finds  its  way  in.  Having  carried  it  in  so  far  as  you  conveniently 
can,  throw  in  your  fluid.  For  this  purpose,  take  care  that  the 
point  of  the  syringe  is  exactly  fitted  to  the  outer  end  of  the 
catheter,  in  order  that  the  fluid  may  be  prevented  from  rushing 
back,  as  it  may  be  necessary  to  use  considerable  force.  The 
quantity  of  fluid  you  are  able  to  get  in  at  first  may  be  very 
small.  Endeavor  to  go  on  increasing  in  quantity,  as  well  as 
strength.  The  catheter  or  tube  made  use  of  should  be  of  silver. 
If  at  any  time  the  caustics  should  produce  irritation  and  inflam- 
mation, or  they  should  occur  during  the  treatment,  suspend  the 
irritating  injections,  and  use  Slippery  Elm  Mucilage.  Give  the 
patient  a  mild  emetic,  followed  by  diaphoretics,  with  perhaps  an 
active  cathartic  or  two,  using  such  other  measures  as  the  case  may 
indicate. 

"As  a  general  rule,  the  injections  must  be  repeated  at  least  once 
a  day.  Twice  a  day  will  be  still  better,  when  they  do  not  pro- 
duce too  much  pain  or  irritation.  The  cavity  of  the  uterus,  as 
well  as  the  vagina,  should  each  time  be  well  washed  out  with 
them." 

503.  In  those  cases  in  which  the  cancerous  deposit  has  extended 
to  the  vaginal  walls,  or  the  tissues  adjoining  the  uterus,  and  in 
which  the  uterus  is  immobile,  and  especially  in  those  cases  in 
which  the  ulceration  has  extended  beyond  the  uterus,  a  radical 
cure  is  impossible.  Here  the  attention  of  the  physician  will  be 
directed  to  the  alleviation  of  the  distress  of  the  patient,  and  to 
checking  the  rapid  progress  of  the  disease.  In  the  furtherance  of 
this  object,  every  possible  cause  of  disease  should  be  removed, 
and  any  injurious  habits  of  the  patient  should  be  stopped.  The 
digestive  powers  should  be  stimulated,  by  the  use  of  the  vegetable 
tonics  and  iron,  and  her  diet  should  be  nutricious.  The  secretions 
should  be  kept  in  good  condition,  the  bowels  regular,  and  the 
kidneys  and  skin  stimulated  to  a  normal  performance  of  their 
functions. 


CAXCEK  OF  THE  UTERUS.  2G1 

504.  Cleanliness  is  of  very  great  importance  in  alleviating  the 
sufferings  of  the  patient.     For  this  purpose,  vaginal  injections  of 
warm    water    should    be    frequently    used ;     in    many    cases,    the 
addition  of  castile  soap,  so  as  to  made  a  weak  suds,  will  be  found 
of  marked  benefit.     If  there  is  much  pain,  narcotics  may  be  added 
to  these  injections.     This  will  be  found  a  much  more  preferable 
mode   of  using  them  than  any  other,  so  long  as  it  gives  relief. 
Thus,  we  may  use  in  this  manner  a  decoction  of  Stramonium,  a 
watery  solution  of  the  extracts  of  Conium,  llyosciamus,  Bella- 
donna, or  a  solution  of  some  of  the  preparations  of   Opium.      A 
decoction  of  Carrots  has  also  been  recommended  as  beneficial,  as 
well   as  water   acidulated  with  Acetic   Acid,  ( 5ss   to    Oct.  j),  or 
Nitric  Acid  (m.x).     These  acidulated  injections  not  only  relieve 
the  pain,  but  they  are  likewise  of   much  benefit  in  checking  the 
discharges. 

505.  Nothing  has  given  me  so  much  satisfaction  in  the  treat- 
ment of  these  unpleasant  cases  as  the  use  of  Carbolic  Acid  and 
Glycerine.     In  some  it  may  he  used  of  the  full  strength  (3iv.  to 
xvj.),  but  in  others  this  will  require  to  be  diluted  with  one  to  four 
parts  of  water.     My  rule  is  to  use  the  strength  that  will  give  the 
greatest  relief  to  pain.     It  is  anaesthetic,  removes  the  fetor,  and 
checks  the  discharges,  lessens  the  rapidity  of  the  growth,  and  in 
some  cases  markedly  lessens  the  size. 

506.  In  the  advanced  stages  of  the  disease,  the  narcotic  injec- 
tions will  not  be  sufficient  to  relieve  the  pain,  and  their  internal 
administration  will  be  found  necessary.    All  the  other  agents  named 
should  be  tried  before  resorting  to  the  preparations  of  opium,  and 
when  this  agent  is  resorted  to,  it  should  be  combined  with  some 
laxative  agent,  to  overcome  its  constipating   effects.     To   relieve 
the  intolerable  fetor  of  the  discharges,  we  may  use  injections  of 
the  Liquor  Sodse  Chlorinata  with  much  advantage. 

507.  The  question  may  here   arise,  can  the  entire  uterus  be 
removed   in    cases    of   cancer,  with    any    probability  of  success? 
In  answer  to  that  question  Velpeau  says,  "  That  the  operation  has 
been  performed  twenty-one  times  in  twenty  years,  and  of  all  of 
these,  not  one  has  been  permanently  cured."     As  this  is  the  case, 
a  description  of  the  method  of  operating  would  be  useless. 


262  DISEASES     OF     WOMEN. 

METRITIS — INFLAMMATION  OF  THE  UTERUS. 

508.  We  may  divide  inflammation  of  tlie  womb  in  the  unirn- 
pregnated    state  into  three  varieties,  according  to   the  intensity 
of  the  disease,  and  its  location.     Thus,  we  have  acute  inflamma- 
tion of  the  entire  structure  of  the  uterus,  chronic  inflammation; 
and   inflammation  of  its  mucous  membrane  or  internal  metritis. 
As  inflammation  of  the  cervix  uteri  has  been  already  described, 
the  description  of  these   forms   of  inflammation  will  apply  more 
particularly  to  the  body  and  fundus  of  the  organ,  i.e.,  all  parts 
above  the  cervix. 

ACUTE  METRITIS. 

509.  This  is  a  very  rare  affection  in  the  unimpregnated  female, 
and  this  rarity  of  the  aifection  is  a  natural  result  of  the  peculiar 
dense,    non-vascular   and  non-cellular    structure    of    the    uterus. 
Tissues  of  this  nature,  says  Dr.  Bennet,-are  but  slightly  suscep- 
tible to  inflammation  as  a  necessary  consequence  of  their  peculiar 
structure  ;    if   the   uterine   system   is   exposed  to   the  causes  of 
inflammation,   its  periphery,  the   mucous  surfaces,  the  cervix  or 
lateral  ligaments,  which  are   so  much  more  highly  vitalized,  are 
generally  the  regions  attacked.     When  the  state  of  the  uterus  is 
modified  by  the  extraordinary  development  and  vitalization  that 
occurs  during  pregnancy,  or  during  the  increase  of  a  large,  fibrous 
tumor,   we   observe  a  different  state  of    things.     If  the  uterine 
system  is  then  exposed  to  the  causes  of  inflammation,  especially 
after  parturition,  the  body  of  the   organ  is  frequently  attacked, 
and  metritis,   observed   under   these   circumstances,   manifests   a 
degree  of  intensity  and   a  virulence  unknown  in  the  unimpreg- 
nated state  of  the  uterus,  but  quite  consistent  with  its  modified 
structure.     In   reality,   the  uterus  is,   anatomically,    a   perfectly 
different   organ  when  unimpregnated,   and   when   developed   by 
impregnation ;  and  its  pathology  is  as  different  in  the  two  con- 
ditions as  its  anatomical  condition. 

510.  Simple  acute  metritis  very  rarely  occurs  in  young  unmar- 
ried persons,  and  still  more  rarely  in  those  who  have  passed  the 
period   for    child-bearing.     In    the    first    case,   the   uterus    still 
retains  its  non-vascular  and  fibro-cartilaginous  character,  though 


ACUTE     MKTRITIS.  263 

sulijeet  to  the  periodical  congestion  of  blood  attendant  on  men- 
struation. In  the  aged,  tlie  uterus  is  atrophied,  inactive,  and 
torpid,  less  liable  to  inflammation  than  most  any  other  tissue  of 
the  body. 

As  regards  the  seat  of  the  disease,  the  entire  uterus  is  more  or 
less  affected,  though  its  peritoneal  investment  is  but  rarely 
involved. 

511.  Causes. — Simple   acute   mctritis   arises   more    frequently, 
perhaps,  from  arrested  menstruation,  than  from  any  other  cause. 
During  the  menstrual  period,  while  the  uterus  is  congested,  and 
the  center  of  a  determination  of  blood,  any  cause  that  will  arrest 
this   secretion  may  give  rise  to  the   disease.     Thus,  during  this 
period,  exposure  to  cold  by  wet  feet,  sitting  on  damp  ground,  etc., 
may  prove  exciting  causes.     Apart  from  the  menstrual  period, 
inflammation  very  rarely  arises,  and,  if    it  does,   it  is  probably 
the  result  of  some  physical  injury  ;  of  a  blow,  or  a  severe  fall,  or 
of  deep  cauterization  of  the  cervix.     It  may,  also,  arise,  in  some 
few  cases,  from  an  extension  of  inflammation  from  the  vagina. 

512.  Symptoms. — The    symptoms    of    this    disease    are    both 
general  and  local.     The  general  symptoms   are  those  which  are 
common  to  the  phlegmasire,  and  they  vary  in  intensity,  according 
to  the  severity  of  the  inflammation.     In  some  cases,  the  disease 
may  be  ushered  in  with  chilliness,  which  is  succeeded  by  fever ;  in 
other  cases,  the  local  symptoms  are  first  manifested,  the  general 
symptoms  being  developed    afterward.     The    pulse    is  generally 
quick,  but  not  small  and  thready  as  it  is  Avhen  the  peritoneum  is 
involved;  the  skin  is  hot  and   dry,  the  feet  generally  cold,  the 
bowels  constipated,  the  stomach  irritable,  and  the  tongue  covered 
with  a  white  fur ;  thirst,   headache,  and  want  of  rest,  sometimes 
with  slight  delirium,  are  present,  as  in  all  febrile  diseases. 

513.  The  most  prominent  local    symptoms  are,  a  severe  and 
deep-seated  pain  above  and  behind  the  pubis,  radiating  from  this 
point    to    the    ovarian  regions,  and  sometimes  down  the  thighs, 
accompanied    by   a  very   disagreeable    sensation    of   weight    and 
uneasiness  in  the  pelvis.     There  is,  also,  generally  a  constant  and 
dull   aching  pain   in   the   back.     Pressure   over   the   hypogastrio 
region  aggravates  the  pain,  and  it  is  also  increased  during  defeca- 


264  DISEASES    OF    WOMEN. 

tion  and  micturition.  Upon  making  an  examination,  the  vagina 
will  be  found  harsh  and  dry,  and  the  secretions  arrested.  The 
inflamed  uterus  is  so  sensitive,  that  its  elevation  by  the  finger  in 
the  vagina  will  give  rise  to  severe  pain,  and  often  to  an  instan- 
taneous sensation  of  nausea.  Dr.  Bennet  states  that,  notwith- 
standing the  extreme  sensitiveness  of  the  uterus,  it  is  possible,  in 
every  case,  to  ascertain,  without  putting  the  patient  to  any  great 
amount  of  pain,  that  it  is  the  uterus  itself  which  is  the  seat  of 
inflammation,  and  not  the  adjoining  tissues.  The  sensitive  tumor 
is  the  immediate  continuation  of  the  cervix,  occupying  the  median 
line,  and  is  equally  painful  on  the  right  and  left  of  that  line ; 
unless,  however,  the  uterus  be  naturally  lying  transversely  from 
right  to  left,  as  is  sometimes  the  case,  when  the  inflamed  organ 
will  extend  more  to  the  right  than  to  the  left  side.  The  rectum 
and  bladder  are  very  frequently  irritated  in  this  disease,  from 
their  close  relation  to  the  uterus  ;  thus  there  is  very  frequently 
pain  in  the  region  of  the  bladder,  with  dysuria,  and  the  irritation 
of  the  rectum  causes  more  or  less  tenesmus,  with  an  increased 
secretion  of  mucus. 

514.  If  inflammation  of  the  uterus  arises  during  the  menstrual 
period,  the  secretion  will  be  suddenly  checked,  while  if  it  arises 
during  the  interval,  the   secretion  will   be  suspended   until  the 
inflammation   is   subdued.      As    has    been   already  stated,    the 
natural  mucous  secretion  of  the  uterus  and  the  upper  part  of  the 
vagina  is  checked  while  the  inflammation  is  at  its  hight ;  but  on 
the  decline  of  the  inflammation,  a  copious  discharge  of  a  variable 
nature  will  often  take  place. 

515.  Treatment. — The  treatment  of  this  inflammation  is  not 
difficult,  if   seen  in  its  commencement.     In  the  first  place,  the 
treatment  should  be  directed  to  a  removal  of  the  congestion  and 
determination  of  blood  to  the  pelvis.      For  this  purpose,  such 
measures  should  be  emplo<yed  as  will  control  the  circulation,  les- 
sen the  temperature,  establish  secretion,  and  remove  the  local 
irritation.     The  sedatives  are  useful  here,  as  in  other  inflamma- 
tory disease,  Aconite  being  the  remedy  most  commonly  indicated. 
It  may  be  combined  with  Macrotys  wben  the  pains  are  tensive, 


ACUTE     METRITIS.  265 

extending  to  the  small  of  the  back  ;  with  JRhus  when  the  pain  is 
burning  and  the  patient  complains  of  frontal  pain,  and  has  the 
peculiar  appearance  of  the  tongue  (red  and  prominent  papillae  on 
the  upper  surface  of  the  tip)  ;  Apocynum  if  there  is  a  disposition 
to  menorrhagia,  or  oedema  of  the  feet ;  Dioscorea  if  there  is  per- 
itoneal pain  or  tenderness;  Apis  if  there  is  itching  with  burning, 
and  painful  micturition  ;  G-ossypium  (tincture  of  the  green  root) 
if  it  is  near  the  menstrual  period,  and  the  discharge  does  not  come 
on  at  the  usual  time;  Santonin  if  there  is  difficulty  and  pain  in 
passing  urine,  or  retention  ;  Belladonna  if  the  patient  is  dull,  in- 
clined to  sleep,  or  there  is  tendency  to  incontinence  of  urine ; 
Gelseminum  if  the  urine  is  scant  and  passed  with  difficulty;  Col- 
linsonia  if  there  is  irritation  of  the  rectum  with  muscular  con- 
traction; Hamamelis  if  there  is  fullness  and  laxness  of  the  peri- 
neal  tissues,  and  evidences  of  venous  congestion. 

516.  I  have  named  some  of  the  more  common  remedies  that 
may  be  employed  in  these  cases,  with  the  most  prominent  symp- 
toms calling  for  their  use.     I  prefer  a  single  strong  and  marked 
symptom  to  any  number  of  indistinct  ones,  and  I  think  the  reader 
will  find  the  ones  named  very  positive  and  certain.     We  have  our 
eases  in  which  the  first  indication  is  to  relieve  irritation  of  the 
stomach,  or  simple  nausea,  which  is  very  common.     And  we  ma}^ 
find  that  Ipecac  with  our  Aconite  in  one  case,  or  small   doses  ot 
Nux  in  the  other,  will  answer  an  excellent  purpose.     Then  we 
have  cases  in  which  the  dirty  pallid  tongue  points  to  Sulphite  of 
Soda,  or  in  which  the  peculiar  fetor  of  breath   and  vaginal  dis- 
charges calls  for  Chlorate  of  Potash.     There  are  cases  with  full 
dirty  tongue,  full  tissues,  and  especially  venous  fullness,  where 
Podophyllin  is  an  excellent  remedy.     When  the  patient  suffers 
from  morning  chills  I  have  found  the  Ignatia  a  most  excellent 
remedy,  giving  it  with  the  Aconite  or  Ehus,  as  may  be  indicated. 
If  the  patient  is  nervous  and  restless  Pulsatilla  may  be  given, 
after  the  acute  symptoms  have  been  removed. 

517.  Rest  is  an  essential  part  of  a  good  treatment,  and  if  it  is 
not  secured,  the  disease  will  be  very  stubborn,  and  will  frequently 
assume  the  chronic  form. 

The  patient  may  have  a  sitz  bath,  or  may  sit  over  a  vessel  and 
have  a  vapor  bath,  or  fomentations  of  hops,  stramonium  or  poppy 
loaves  may  be  used.  Sometimes  benefit  is  derived  from  quinine 


266  DISEASES     OF     WOMEN. 

inunction  over  the  abdomen,  or  if  there  is  much  tenesmus,  an 
enema  of  Opium  and  Lobelia  sometimes  gives  relief. 
CHRONIC  METRITIS. 

518.  Chronic  inflammation   of  the   body  of  the   uterus,  is   of 
much  more  frequent  occurrence  than  the  acute  form.     It  occurs 
most  commonly  in  the   married,  and  in  those  who  have  had  fre- 
quent labors,  either  natural    or  unnatural.     It  is  not,   however, 
confined  to  these,  for  unmarried  persons  who  have  passed  the  age 
of  puberty,  are  also  liable  to  the   affection.     Chronic  inflamma- 
tion  of  the  uterus,  unlike   the   acute  form,    does    not  generally 
extend  to  the  entire   structure  of  the  uterus,  but  is  confined  t^  a 
circumscribed  part  of  it.     Dr.  Bennet  states :  "  That  in  this  par- 
tial form,  it  is  observed  in  nine  cases  out  of  ten,  in  the  posterior 
wall  of  the  uterus  in  its  inferior  region,  immediately  adjoining  the 
cervix.     The  predilection  of  chronic  metritis  for  this  particular 
region  is  probably  accounted  for  by  the  band  of  longitudinal  mus- 
cular  fibers  which   pass   into  the  posterior  region   of  the  cervix, 

•from  the  posterior  wall  of  the  body  of  the  uterus,  chronic  metritis 
being  generally  the  result  of  extension  to  the  uterus  of  chronic 
inflammation  of  the  cervix.  It  may,  however,  exist  in  the  anterior 
uterine  wall,  or  laterally." 

519.  Causes. — Chronic  inflammation  of  the  body  of  the  uterus 
arises  most  frequently  from  an  extension  of  deep-seated  inflam- 
mation  of  the  cervix ;  it  may,  however,   be  the   termination  of 
acute  inflammation,  whether  puerperal  or  not.     It  may  also  arise 
from  syphilis,  which,  by  infecting  the  whole  system,  often  becomes 
a  cause  of  uterine  disease. 

520.  Symptoms. — The  symptoms  of  chronic  metritis  are  suffi- 
ciently well  marked,  if  closely  observed.     In   a  state  of  health, 
there  are  no  indications  by  which  the  patient  may  know  that  such 
an  organ  as  the  uterus  exists.     In  chronic  inflammation,  however, 
both  its  existence  and  locality  are  well  marked,  by  the  unusual 
sensations  felt  in  that  region,  as  a  sensation  of  weight  and  drag- 
ging down,  pain  more  or  less  severe,  etc.     The  pain  experienced, 
is  referred  by  the  patient  to  the  region  immediately  above  and 
behind  the  pubis ;  it  is  generally  constant,  dull  and  deep-seated. 
There  is  also  a  continuous  dull,  heavy  pain  in  the  small  of  the 


CHKOXIC     METRITIS.  267 

back,  or  a  sensation  of  great  weakness  at  that  point;  tliis  pain 
frequently  extends  around  the  groins,  and  to  the  ovarian  region. 
Another  marked  symptom  of  uterine  disease  which  is  present 
here,  is  a  constant  pain  or  soreness  in  the  thighs,  sometimes 
extending  to  the  entire  lower  extremities.  Exercise  almost  always 
aggravates  these  symptoms,  even  the  erect  position  often  increases 
the  pain. 

521.  The    rectum   and    bladder    almost    always    suffer    either 
directly  or  sympathetically  with  the  diseased  uterus.     Thus,  the 
continuance  of   the  inflammation  for  any  length  of  time  causes 
an   enlargement   of  the   organ,   and   thereby   an    increase    of  its 
weight.     This  increase  of  weight  in  the  majority  of  cases,  causes 
more  or  less  displacement;  thus,  if  the  inflammation  is  located  in 
the  posterior  wall  of  the  uterus,  the  tumefaction  and  enlargement 
of  this  part  will  cause  a  displacement   of  the   fundus   backward 
against  the  rectum.    This  displacement  does  not  generally  involve 
the  entire  organ,  the  cervix  not  being  thrown  forward  against  the 
bladder;    we  have   not,  therefore,  retroversion,   but   retroflexion, 
the  cervix  forming  an  angle  with  the  body  of  the  uterus.     This 
displacement  of  the  uterus  backward,  and  its  consequent  pressure 
upon  the  rectum,  gives  rise  to  inflammation  of  the  bowel,  marked 
by  pain,  especially  toward  the  anus ;  it  also  causes  at  times,  a 
marked  tenesmus,  with  a  hyper-secretion  of  mucus,  which  is  dis- 
charged each  time  the  patient  goes  to  stool.     Another  effect  of 
this  displacement,  is  a  difficulty  in  passing  the  fasces,  and  when 
they  are  passed,  the  action  of  the  bowels  is  always  accompanied 
with  severe  pain  from  the  pressure  of  the  contents  of  the  bowel 
upon  the  inflamed  uterus.     If  the  anterior  wall  of  the  uterus  is 
the  part  mostly  affected,  the  displacement    of  the  uterus  will  be 
anterior,  and  its  pressure  will  be  upon  the  bladder ;  this,  however, 
seldom  occurs. 

522.  Upon  making  an  examination  in  this  disease,  the  uterus 
will  generally  be  found  enlarged  and  very  sensitive  to  the  touch. 
Dr.  Bennet  states,  "  that  when  the  inflammation  is  partial  only, 
the  finger  passed  carefully  behind,  before,  and  on  the  sides  of  the 
uterus,  carrying  the  cul-de-sac  of  the  vagina  before  it,  so  as  to 
explore    its   walls,    readily    discovers    the    seat    of    the    disease. 


2G8  DISEASES     OF     WOMEX. 

Instead  of  the  finger  passing  from  the  base  of  the  uterine  neck 
on  to  a  smooth,  insensible  surface,  a  continuation  of  the  plane 
formed  by  the  cervix,  it  meets  with  an  exceedingly  sensitive 
elevation  or  protuberance,  sometimes  quite  regular,  sometimes 
irregular  and  knotty.  In  the  latter  case,  however,  the  nodosities 
that  diversify  the  tumefied  surface  are  all  perfectly  spherical ;  there 
are  no  knife-back  ridges  or  sharp  irregularities.  Pressure  on  this 
tumefied  surface  is  exceedingly  painful.  Occasionally  there  is  no 
perceptible  tumefaction,  but  merely  an  exquisite  sensitiveness  in 
a  limited  region  of  the  uterus ;  pressure  giving  rise  to  the  sensa- 
tion of  sickness.  The  uterus  is,  in  most  instances,  quite  movable, 
but  the  attempt  to  move  it  is  attended  with  great  pain.  After  the 
disease  has  continued  for  some  time,  the  general  health  will  be 
found  to  suffer.  The  appetite  will  become  impaired,  digestion 
feeble,  and  the  patient  emaciated.  In  these  cases  the  countenance 
will  always  present  a  pale  and  sallow  appearance,  with  an 
expression  of  pain  and  languor,  which  is  always  more  marked  at 
the  menstrual  period." 

523.  The  presence  of  chronic  metritis  of  the  variety  we  are 
now  considering,  does  not  always  give  rise  to  a  vaginal  discharge ; 
most  generally,  however,  there  is  a  white  or  transparent  leucorr- 
heal  discharge.     This   discharge   sometimes   assumes    a   peculiar 
dark-brown  color  for  two  or  three  days  before  or  after  menstrua- 
tion, being  caused  by  an  admixture  of  Wood  corpuscles  and  mucus 
thrown  off  from  the  lining  membrane  of  the  uterus,  or  from  its 
inflamed  portion,  during  the  menstrual  congestion. 

524.  Treatment. — If  this  disease  has  arisen  from  an  extension 
of  inflammation  of  the   cervix  uteri,  or  if  inflammation  of  the 
cervix  has  arisen  during  the  course  of  this  disease,  this  should 
first  be  removed  by  the  means  alreadjT  spoken  of.     As  heretofore 
named,  the  acute  disease  must  be  treated  with  reference  to  a  pos- 
sible chronic  inflammation,  for  many  times  the  patient  feeling 
better,  is  inclined   to  dispense  with  treatment  before  a  cure  is 
effected.     It  is  also  well  to  notice  that  physical,  mental,  and  sex- 
xial  rest  is  indispensable  in  some  cases,  and  very  important  in  all. 
If  a  patient  can  be  sent  away  from  home,  where,  in  addition  to 
rest,  there  will   be  change  of  scene  and  pleasant  company,  very 


CHRONIC     METRITIS.  269 

simple  remedies  will  sometimes  effect  a  cure.  Here,  as  elsewhei'e, 
remedies  must  be  carefully  selected.  We  have  no  invariable 
treatment  for  chronic  metritis.  Each  case  must  have  its  analysis, 
and  the  remedies  must  be  selected  to  meet  it  especially.  We  want 
to  know  the  condition  of  the  body  at  large,  both  in  its  structure 
and  function,  and  we  want  to  know  the  exact  condition  of  the 
uterus  and  associate  organs.  The  rule  is.  the  better  the  general 
health  the  more  surely  and  rapidly  we  can  remove  local  inflam- 
matory disease.  We  want  good  digestion  and  blood-making,  a 
good  circulation,  good  nutrition,  and  good  waste  and  excretion. 
Our  patient  may  want  alkalies,  acids,  tonics,  the  restoratives,  or 
agents  to  act  upon  skin,  kidneys,  bowels  ;  and  finding  the  want 
we  do  that  which  is  necessary. 

525.  When  we  think  of  special  means,  it  suggests  itself  that 
those  remedies  which  influence  the  reproductive  function  will  be 
especially  important,  and  so  we  find  it  in  practice.  In  some  cases 
the  peculiar  tensive,  twisting  pain.  Avith  muscular  soreness,  calls 
for  Macrotys,  and  if  the  patient  is  nervous,  with  the  addition  of 
Pulsatilla.  In  many  cases  it  is  well  to  use  it  for  a  week  before 
the  menstrual  period,  and  until  this  is  well  established,  and  then 
put  the  patient  upon  other  remedies.  Rhus  will  be  found  an  ex- 
cellent remedy  in  some  cases,  the  peculiar  appearance  of  tongue 
and  burning  pain  being  the  indication.  Ignatia  is  the  remedy 
suggested  by  morning  chills, — "feels  better  in  the  open  air" — • 
and  a  sense  of  constriction  and  soreness  around  the  waist.  Some- 
times there  is  the  double  indication  for  Rhus  and  Ignatia.  The 
Mitchella  is  a  good  remedy,  and  may  be  used  when  there  is  a 
sense  of  uneasiness  and  weight,  and  weakness  of  the  tissues  along 
the  pelvic  outlet.  Hamamelis  is  a  remedy  indicated  in  every  case 
by  the  lax  condition  of  the  tissues,  and  venous  fullness.  The 
Gossypium  (tincture  of  the  green  root)  may  be  given  to  favor  the 
menstrual  flow  when  it  is  tardy,  scant  or  arrested,  but  it  must  be 
used  with  care,  for  it  sometimes  increases  the  inflammatory  action. 
Iodide  of  Potash  will  prove  a  useful  remedy  when  the  tongue 
is  full,  pallid,  and  leaden  colored.  The  Iodide  of  Ammonium 
when  the  patient  suffers  from  dull  headache,  involving  the  top 
and  back  of  the  head,  or  the  whole  head.  The  Bromide  of  Am- 
monium is  indicated  by  hysterical  manifestations,  in  any  form, 
especialty  by  convulsions.  To  remove  inflammatory  deposits  the 


270  DISEASES     OF     WOMEN. 

Acetate  of  Potash  may  sometimes  be  used,  largely  diluted,  for 
daj'S  together.  If  the  tongue  is  pallid  and  dirty,  give  the  Sul- 
phite of  Soda  until  this  condition  is  removed.  If  the  tongue  is 
full,  face  sallow,  veins  full,  dizziness,  give  the  minute  dose  of  Po- 
dophyllin  with  Hydrastia. 

52H.  As  regards  local  applications,  we  will  sometimes  find  the 
most  advantage  from  the  use  of  the  vinegar  pack,  applied  at 
night,  with  thorough  sponging  with  cold  water  and  drying  in  the 
morning.  In  some  the  irritating  plaster  over  the  uterus  will  give 
good  results  ;  it  may  be  used  simply  to  produce  a  crop  of  pus- 
tules, or  to  free  suppuration.  In  place  of  this,  thorough  quinine 
inunction  to  the  abdomen  ma}'  sometimes  be  used. 

INTERNAL   METRITIS — UTERINE    CATARRH — UTERINE 
LEUCORRHEA. 

527.  The  seat  of  this  inflammation  is  the  mucous  membrane 
lining  the  uterus  ;  it  may  involve  the  entire  lining  of  the  cavity 
of    the    uterus  and  of    the    cervix,   but,   in   this   last   case,   it  is 
generally  complicated  with  inflammation  of  the  cervix.     It  may 
be  either  acute  or  chronic,  though  the  disease  is  most  generally 
seen  in  the  chronic  stage. 

528.  Like    the    other    forms    of    uterine    inflammation,    this 
generally   occurs    in   females   between   the    ages    of  twenty  and 
forty,  though,  in  some  few  instances,  it  may  be  observed  at  an 
earlier  or  later  age  than  this.     It  also  arises  most  frequently  in 
those  who  have  had  many  labors,  either  natural  or  unnatural. 

529.  Pathological  Anatomy. — According  to  Prof.  Rokitansky, 
*'  the    uterine    mucous  membrane   is  much  more  commonly   dis- 
covered in  a  state  of  chronic  catarrh  and  inveterate  blennorrhea, 
which  is  either  the  residue  of  acute   catarrh,  or  the   result  of  a 
similar  affection   of    the  vagina  ;  it  may   occur  as  a  sequelae  of 
parturition,   or  as   a  complication  of  those  morbid  growths  that 
bear  a  near   relation    to    the    uterine    mucous    membrane.     The 
mucous  membrane  offers  a  pallid  appearance,  or  there  is  evidence 
of  previous  stasis  and  inflammation,  and  it  then  presents,  with  the 
adjoining  uterine  tissue,  a  brownish-red,  or  slaty  color  ;  the  mem- 
brane is  tumefied,  relaxed,  plicated,  and  secretes  a  grayish-white 
viscid   mucus,    which,    during    temporary   exacerbations,    or    an 


UTERIXE     LEUCORRHEA.  271 

enduring   state  of   more  intense  inflammation,   appears  streaked 
with  blood,  creamy,  yellow,  and  puriforin. 

530.  "  Here,  too,   AVC   find   hypertrophy  of  the  mucous  mem- 
brane, resulting  from  chronic  catarrh,  in  the  shape  of  mucous  or 
cellular  polypi.     They  consist  of  club-headed  elongations  of  tha 
mucous  membrane,  in  which  we  find  a  group   of  closed  follicles, 
or  a   tabulated  tissue,  containing  a  gelatinous  mucus,  which  is  dis- 
charged from  time  to  time,  in  consequence  of  a  dcliiscence  of  the 
follicles.     These  excrescences  occur  chiefly  at  the  fund  us  uteri,  in 
the  neighborhood  of  the  insertions  of  the  fallopian  tubes,  and  in 
the  canal  of  the  cervix,  a  point  at  which,  in  the  normal  condition, 
large    follicles,    (ovuli  Nabothi,)  arc    found,    which    occasionally 
undergo  considerable  enlargement. 

531.  "  We  find  that  the  uterine  parenchyma  becomes  more  or 
less  hypertrophied  during  catarrh,  in  the  same  manner  as  other 
muscular  layers  which  are  subjacent  to  mucous  membranes. 

532.  "  Inveterate  uterine  catarrhs  not  unfrequently  give  rise  to 
stricture  and  atresise,  and,  if  the  blennorrhea  persists,  to  dilata- 
tions of  the  uterine  and  cervical  cavities.     During  the  progress 
of    dilatation,    occurring    under    these    circumstances,    the    same 
changes  that  we  have  repeatedly  met  with  under  similar  circum- 
stances, in  dropsy  of  mucous  cavities  and  canals,  are  sometimes 
found  to  occur  in  the  uterus.     As  a  dilatation  from  the  accumu- 
lated    secretion     increases,    the     uterine    mucous    membrane    is 
converted  into  a  thin,  serous  membrane,  which  secretes  a  color- 
less, serous,  albuminous   fluid,  resembling   synovia.     The   uterus 
appears  in    the    shape  of   a   round,  slightly-thickened,  hydropic 
capsule,  of  the  size  of  a  hen's  or  duck's  egg,    or  a  fist.     This 
condition  is  the  only  one  that  really  deserves  the  name  of  hydro- 
metra,  of  which  several  remarkable  instances  are  related,  especially 
by  older  writers.     The  contained  fluid  may  always,  or  for  a  long 
time,  remain  such  as  above-described ;  but  it  generally  undergoes 
some  alterations  from  the  admixture  of  various  products  of  slight 
inflammatory  attacks,  and  especially  of  hemorrhagic  exudations 
of  the  uterine  lining,  which    give  it  a   chocolate-colored,  rusty, 
or  black  tinge.     Occasionally  temporary  discharges  of  these  fluids 


272  DISEASES     OF     WOMEN. 

occur  by  the  vagina  during  life,  after  which  fresh  accumulations 
take  place." 

533.  Uterine  catarrh  generally  suffices   to  produce  sterility; 
but  it  often  extends  to  the  fallopian  tubes,  and  there  gives  rise 
to  changes  that  are  of  extreme  importance  in  this  repect. 

534.  Causes. — All  the  causes  heretofore  spoken  of  as  giving 
rise  to  the  other  two  forms  of  metritis,  may  give  rise  to  this, 
^hus,  it  may  arise  from   exposure  to  cold  during  the  menstrual 
period,  or    after  parturition   or  abortion,    from  an  extension  of 
inflammation   of  the  cervix  uteri  or  vagina,  etc.     It  arises  very 
frequently    from    the    sudden    cessation    of   natural    or    artificial 
excretions,  as   of   general   or  local  perspiration,  the  suppression 
of  a  diarrhea,  or   habitual  vomiting,  of  hemorrhoidal  discharges, 
etc. 

535.  The  predisposing  causes  of  the  disease  are  frequent  child- 
bearing,    habitual    abortions,    excessive    sexual    intercourse,    etc. 
Any    cause    calculated    to    debilitate    the    genital    organs   or  the 
general   health,  will   prove  predisposing  causes   of  this    disease. 
M.  Colombat  cites,  as  predisposing  causes  of  this  as  well  as  other 
uterine  diseases  in  large  cities,  idleness,  effeminacy,  a  sedentary 
life,  the  constant  contact  of  the  two   sexes,  and  the  frequenting 
of  places  where  everything  inspires  pleasure ;  prolonged  watch- 
ing, da'ncing,  frivolous  occupations,  and  the  study  of  the  arts  that 
give  new  activity  to  the  imagination  ;    erotic   reading,    the  per- 
nicious establishment  of  an  artificial  puberty,  etc. 

536.  Symptoms. — In  the  early  stage  of  the  disease  the  symp- 
toms   are  not   very  well    marked,  and    its    general   complication 
with  other  diseases  of  the  uterine  organs  conspire  to  make  its 
diagnosis  extremely  difficult.     This  difficulty  in  determining  the 
seat  of  the  disease,  however,  becomes  much  less  as  the  disease 
advances.     Dr.  Bennet  states,  that  internal  metritis  may  be  said 
to   exist  to   a   certainty,   if  the   os  internum  of  the  cervix  is  so 
completely  open  as  to  allow  the  uterine  sound  to  pass  freely  into 
the  uterine  cavity  ;  if  that  cavity  is  increased  in  size,  and  more 
sensitive,   and  if,  likewise,  there  is  a  more   abundant  sero-san- 
guinolent    discharge,   accompanied  by  dull,  deep-seated  pain  in 


UTERINE     LEU  COR  RUE  A.  273 

the  region  of  the  uterus  itself,  that  is,  behind  and  slightly  above 
the  pubis,  and  by  a  certain  amount  of  febrile  reaction. 

537.  It    may  be   stated,  as  a  general   rule,  that  the  mucous 
membrane  of  the  cavity  of  the  uterus  never  suffers  from  inflam- 
matory action,  without  the   canal  of  the   cervix  is  also   affected. 
With   the  discharge  from  the   cavity  of  the   uterus,  therefore,  we 
nave  more  or  less  of  the  peculiar  secretion  from  the  canal  of  the 
cervix,  the  highly  albuminous,   transparent,  white  of  egg  mucus, 
the  two  secretions  being  intimately  mixed.     This  sero-sanguino- 
lent  secretion  from  the  uterine  cavity  is  never  observed  only  when 
the  inflammation  is  acute,  or  sometimes  for  one  or  two  days  pre- 
ceding or  following  the   catamenial  period.     At  other  times,   the 
discharge  from  this  cavity  is   of  a  grayish-white  color,  or,  if  the 
disease   is   of    very   long   standing,   the   discharge   may   be    thin, 
serous,  and  albuminous,  resembling  synovia,  or  chocolate-colored, 
rusty,  or  brownish-black.     The  admixture  of  the  secretions  from 
the  canal  of  the  cervix  and  the  uterine  cavity,  and  the  constant 
presence  of  the  cervical  secretion  in  large  quantities,  prevents  us 
from  determining  the  extent  of  the  inflammatory  process  in  the 
uterine  cavity  by  the  secretions. 

538.  The  secretion  from  the  entire  uterine  mucous  membrane 
varies  much  in  quantity.     Sometimes  it  is  very  profuse,  obliging 
the  patient  to  use  several  napkins  per  day.     The  principal  part  of 
this  discharge  consists   of  the   transparent  mucus  of  the  cervix, 
mixed  with  the  secretion  of  the  uterine  cavity,  which  sometimes 
gives    it    a    greenish    or    brownish    tinge.     At    other    times,    the 
discharge,  whether  large  or  small,  will  consist  principally  of  the 
secretion  heretofore  described  as  coming  from  the  uterine  cavity. 

539.  In  some  rare  instances  inflammation  of  the  mucous  mem- 
brane of  the  uterus  is  followed  by  ulceration.     When  this  is  the 
case,  the  cavity  of  the  uterus  becomes  considerably  enlarged,  and 
large  quantities  of  pus,  blood  and  mucus  collect  within  it,  and  are 
expelled  through  the  os  uteri.     In  a  case  that  I  have  lately  been 
treating,  there  was  a  profuse  discharge  of  mucus  and  pus  from  the 
uterine  cavity,  but  instead  of  its  being  continuous,  as  is  generally 
the  case,  it  would  come  on  periodically,  twro,  three  or  four  times  a 
dav,  and  be  accompanied  with  severe  pain,  the  uterus  appearing 

18 


274  DISEASES     OF     TVOMEX. 

to  contract  upon  its  contents  to  expel  them.  At  each  one  of  these 
paroxysms  there  would  be  expelled  from  a  drachm  to  half  an 
ounce  of  muco-pus ;  the  discharge  would  then  continue  from  half 
in  hour  to  an  hour,  and  then  cease  until  the  next  paroxysm. 

540.  According    to  Dr.  Bennet,  "internal    metritis  is  nearly 
always  accompanied  by  a  dull,  aching  pain  in  the  back  or  ovarian 
regions,  similar  to  that  experienced  in  inflammation  of  the  cervix, 
and  by  deep-seated  pain  in  the  region  of  the  uterus.     The  uterus 
is  generally  rather  swollen,  enlarged,  and  sensitive  to  the  touch, 
the  entire  organ  being  in  a  congested,  irritable  state.     Internal 
metritis  is  also  often  accompanied  by  a  slight  amount  of  febrile 
reaction,    occurring    at    intervals,     after    exertion,    instrumental 
interference,  or  at  the  monthly  periods.     The  catamenia  are  often 
disordered,  generally  manifesting  themselves  more  frequently  and 
more  abundantly,  lasting  longer,  and  being  attended  with  more 
pain  than  usual.      Sometimes  the  flow  of  blood  is  so  great  and  so 
lengthened  as  to  constitute  flooding,  and  this  is  more  especially 
observed,   as   might   be   anticipated,   when  the   sero-sanguinolent 
discharge    is    present.      With    some    patients,    however,    on   the 
contrary,  the  menstrual  secretion  appears  to  be  diminished ;  but 
in  either  case  it  may  be  laid  down  as  a  rule,  that  the  disease  is 
aggravated  by  the  appearance  of  menstruation.     In  addition  to 
these  symptoms,  all  the  general  sympathetic  reactions  which  are 
observed  in  chronic  metritis,  and  in  chronic  inflammation  of  the 
cervix,  may  be  present.     As  internal  metritis  is  generally  com- 
plicated  with   these    diseases,   we   may  also    have    the    peculiar 
symptoms  which  they  present." 

541.  Inflammation  of  the  uterine   mucous  membrane  in  the 
acute  form,  may  terminate  in  resolution.     This  termination,  how- 
ever, is  very  uncommon,  unless  the  disease  is  seen  at  this  time, 
and  judiciously  treated,  the  acute  inflammation  generally  running 
into  the  chronic  blennorrhagic  form.     When  the  inflammation  has 
become  chronic,  there  is  no  prospect  of  its  terminating  spontane- 
ously, at  least  until  the  age  when  the  menstrual  secretion  ceases. 
The  periodical  recurrence  of  the  menstrual  congestion  appears  to 
be  sufficient  to  keep  up  the  chronic  inflammatory  process  inde- 
finitely.    At  the   period   of  the  cessation   of   the  menses,   this 


TTEKIXK     LEUCORRIIEA.  275 

inflammation  likewise  ceases  :  the  periodical  congestion  which  has 
kept  it  up,  having  stopped.  The  effect  the  disease  has  upon  the 
system,  varies  much  ;  thus,  in  some  women  of  strong  constitution, 
and  where  the  discharge  is  not  large,  it  may  affect  the  general 
health  but  slightly;  in  other  cases,  however,  the  effect  of  the 
disease  is  very  strongly  marked,  the  patient  is  very  much  debili- 
tated, and  it  may  even  occasion  death  indirectly,  bv  exposing  her 
thus  weakened  and  reduced,  to  the  development  of  incidental 
affections,  as  consumption,  dropsy,  etc.  This  debility  of  the  sys- 
tem is  caused  in  two  ways  ;  first,  by  the  quantity  of  the  discharge, 
it  often  being  very  profuse,  amounting  to  from  one  to  four  ounces 
per  day,  and  continuing  thus  for  years,  it  exhausts  the  system  by 
its  constant  drain  upon  it;  and  second,  by  sympathy,  the  stomach 
and  digestive  organs  always  sympathizing  more  or  less  with  the 
diseased  uterus. 

542.  Treatment. — In  the  acute  stage  of  this  disease,  the  treat- 
ment is  very  easy,  being  the   same  that  we  adopt  in  other  local 
inflammations.      The  warm  foot-bath,  internal  use  of  diaphoretics, 
the  warm  hip-bath,  fomentations  over  the  hypogastrium,  etc. ;  in 
fact,  the  same  treatment  recommended  for  acute  metritis,  is  indi- 
cated here.     The  disease,  however,  will  very  rarely  be  seen  pre- 
senting these  acute   symptoms,  the  patient  generally  consulting 
the  physician  on  account  of  the  leucorrheal   discharge,   and  its 
accompanying  symptoms. 

543.  In  the  chronic  stage,  or  uterine  leucorrhea,  the  disease  is 
often  very  obstinate,  not  yielding  very  readily  to  any  treatment. 
Here,  if  the   cervix  be  diseased,  as  is  very  often  the  case,  our 
treatment  should   be  first   directed   to   its  removal,  for  with  the 
removal  of  the  inflammation  of  this  part,  we  will  have  removed 
the  exciting  cause  of  the  inflammation  of  the  uterine  cavity.    The 
same  treatment  that  has  been  already  recommended  for  inflamma- 
tion of  the  cervix  should  be  pursued  here,  paying  especial  atten- 
tion to  the  treatment  of  the  canal  of  the  cervix. 

544.  The  constitutional  treatment  in  this  disease,  is  of  the  first 
importance,  for  by  restoring  the  general  health  and  the  quality 
of  the  blood,  we  break  up  the  tendency  to  inflammatory  action. 
Thus,   our  first  object   should   be   to   increase    the    tone   of    the 


276  DISEASES     OF     TTOMEX. 

digestive  organs,  and  the  quantity  and  quality  of  the  blood ;  and 
in  accomplishing  this,  we  may  make  use  of  such  agents  as  directly 
increase  the  tone  of  the  uterine  organs.  Thus,  we  may  use  with 
much  advantage,  the  various  preparations  of  iron,  with  the 
Hydrastis,  Helonias,  Cornus,  Cerasus,  Caulophyllum,  Senecio, 
Eumex,  etc.  These  agents  not  only  prove  general  tonics,  but 
they  likewise  have  a  specific  effect  on  the  uterine  organs,  counter- 
acting the  debility  produced  by  the  disease.  The  Ferrated  Tinc- 
ture of  Peruvian  Bark,  or  the  Compound  Syrup  of  Partridge 
Berry,  with  Hydrastis  and  Carbonate  of  Iron,  will  also  be  found 
very  beneficial  agents. 

545.  With  the  use  of  these  remedies  to  restore  the  general 
health  of  the  patient,  it  is  necessary  to  pay  strict  attention  to  the 
condition  of  the  bowels,  the  kidneys,  and  the  skin.  Without  the 
different  excretory  organs  are  stimulated  to  a  full  performance  of 
their  functions,  it  is  impossible,  in  the  majority  of  cases,  to  per- 
manently relieve  the  morbid  uterine  discharge.  In  nearly  every 
case  of  this  kind  we  will  find  the  bowels  irregular,  either  consti- 
pated, or  less  frequently  a  chronic  diarrhea,  or  an  alternation 
between  constipation  and  diarrhea;  the  secretion  of  urine  will 
likewise  be  found  altered,  generally  the  urine  will  be  passed  in 
smaller  quantities  than  natural ;  in  some  cases  it  will  be  found 
albuminous,  and  in  others  it  will  be  normal  in  quantity,  but  of 
low  specific  gravity.  The  skin  will,  in  a  great  majority  of  cases, 
either  be  found  harsh  and  dry,  with  very  little  or  no  perspiration, 
at  any  time,  or  it  will  have  a  soft,  flabby,  and  doughy  feel ;  and 
if  there  be  perspiration,  __ it  will  generally  be  cold  and  clammy. 
Each  of  these  morbid  conditions  will  have  to  be  removed,  and  the 
organs  stimulated  to  a  normal  performance  of  their  functions. 
Thus,  if  the  bowels  are  constipated,  as  is  most  frequently  the 
case,  the  combination  referred  to  under  the  head  of  chronic 
metritis,  will,  in  a  majority  of  cases,  remove  the  difficulty;  with 
the  use  of  any  laxative  preparation,  however,  if  we  expect  to 
succeed  in  removing  the  tendency  to  constipation,  we  will  have 
to  distinctly  impress  upon  the  mind  of  the  patient  the  importance 
of  having  a  fixed  time  to  evacuate  the  bowels,  and  at  this  time  it 
should  be  attended  to,  no  matter  what  circumstances  occur  that 


UTERINE     LEUCORRIIEA.  277 

would  make  it  inconvenient.  If  this  rule  be  observed,  a  habit 
will  be  formed,  and  after  a  short  time  an  action  from  the  bowels 
will  take  place  at  the  regular  time,  without  the  use  of  purgatives. 
To  stimulate  the  kidneys  to  action,  we  may  use  agents  that,  while 
they  accomplish  this  purpose,  will  have  a  direct  beneficial  influence 
on  the  disease.  In  some  cases  we  obtain  marked  benefit  from  the 
old-fashioned  prescription  of  Copaiba  and  Cubebs,  or  Cubebs  with 
Carbonate  of  Iron.  In  others  the  tincture  of  the  Muriate  of  Iron 
will  be  useful,  as  in  the  following: — 

R  Tincture  of  Muriate  of  Iron,  $ss. 

Glycerine,  giss.     M. 

One-third  of  a  teaspoonful  every  two  hours.  The  Eryngium, 
Hydrangea,  Staphysagria,  Phosphorus,  and  the  tonic  and  astrin- 
gent diuretics  may  also  prove  useful. 

To  remove  the  peculiar  morbid  condition  of  the  cutaneous  sur- 
face, and  promote  free  secretion  from  it,  we  make  use  of  the 
alkaline  wash,  using  it  once  or  twice  a  day,  with  considerable 
friction.  If  the  patient  be  much  debilitated,  the  addition  of 
spirits  to  the  wash  will  be  beneficial.  In  many  cases,  especially 
those  in  which  the  skin  is  harsh  and  rough,  the  wet  sheet-pack 
used  once  or  twice  a  week,  will  often  be  followed  by  a  marked 
improvement,  both  in  the  general  health  and  the  local  disease. 

546.  Under  the  general  treatment  above  recommended,  a 
marked  improvement  will  soon  be  observed ;  the  strength  will  be 
increased,  the  appetite  improved,  the  excretions  will  be  in  normal 
quantity  and  quality.  This  of  itself  will  relieve  the  uterine 
inflammation  in  the  majority  of  cases,  and  stop  the  leucorrheal 
discharge.  In  some  cases  the  careful  selection  of  special  reme- 
dies will  give  better  results  than  we  obtain  from  the  general  means 
named,  but  in  others  they  will  supplement  them.  I  have  seen 
cases  cured  with  a  single  remedy,  as  the  Graphites,  or  Carbo-veg., 
which  had  resisted  all  the  means  employed  for  many  months. 
It  is  true  we  can  not  always  find  the  indication  for  the  special 
remedy,  but  it  is  just  as  true  that  we  can  look  for  it  carefully. 
Read  over  the  remedies  named  in  inflammation  of  the  cervix,  and 
acute  and  chronic  metritis,  and  if  the  symptoms  indicating  them 
are  found  here,  use  them.  I  have  had  good  results  from  the 


DISEASES     OF     WOMEN. 

Hamamelis,  Viburnum,  Macrotys,  Caulophyllum,  G-ossypium,  Pul- 
satilla,  Staphysagria,  Cuprum,  arsenic,  etc. 

547.  As  already  stated  before,  our  local  medication  should  be 
first  directed  to  the  removal  of  any  inflammation  or  other  disease 
that  may  exist,  of  the  cervix  uteri,  or  the  vagina.     Especially 
should  the  condition  of  the  canal  of  the  cervix  be  ascertained, 
and  if  diseased,  it   should  be  treated  in  the   manner  heretofore 
described.     After  the  inflammation  of  the  vaginal  portion  of  the 
uterus  has  been  removed,  but  little  more  can  be  accomplished  by 
topical  applications.     The  use  of  the  cold-water  injections,  how- 
ever, should  be  still  continued,  as  by  this  means  the  vagina  and 
cervix  will  be  kept  in  a  healthy  condition. 

548.  Injection    into  the  cavity  of  the  uterus  has  been  recom- 
mended and  put  in  practice  by  some  physicians.     Dr.  Simpson 
states  "  that  he  has,  of  late,  applied  nitrate  of  silver,  etc.,  to  the 
lining  membrane  of  the  cavity  of  the  uterus,  in  cases  of  uterine 
leucorrhea,    and    of    dysmenorrhea,   connected    Avith   a   morbidly 
sensitive  state  of  portions  of  the  inner  surface  of  the  organ,  as 
ascertained   by   the    bougie,   and   with   membranous,    sub-inflam- 
matory   effusions ;     in    chronic    suppression    of     the    menstrual 
discharge,    etc.       The    results    proved,    that    while    direct    local 
applications  could  thus  be  made,  with  perfect  ease  and  safety,  to 
the  diseased  lining  membrane  of  the  uterine  cavity,  the  effects 
were  such  as  to  lead  to  the  hope  of  a  successful  issue  in  some 
cases    of    uterine    disease,    otherwise    almost    or   indeed    totally 
unmanageable."     In  applying  these  agents  to  the  uterine  cavity, 
Dr.  Simpson  uses  an    instrument  similar  to  Lallemand's  porte- 
caustic.     In  this  treatment  of  Dr.  Simpson's,  Dr.  Bennet  partially 
coincides.     After  recommending  it  as  a  last  resort  in  severe  cases 
of  internal  metritis,  he  says:   "The  cavity  of  the  uterus  bears 
surgical  interference,  as  we  have  seen,  less  than  any  other  uterine 
region ;    its    cauterization    being    nearly    always    attended    with 
extreme  pain,  nausea,  or  even  sickness,  copious  hemorrhage,  and 
considerable  febrile  reaction."     Dr.  Ashwell  describes  a  case  of 
inveterate  leucorrhea,  in  which  he  used  an  injection  of  Sulphate 
of  Zinc,  gr.  iij.  to  Warm  Water  Si.     There  were  no  immediate 
effects :  but  in  about  six  or  seven  hours  there  was  agonizing  pain 


TYMPANITIS     UTERI.  279 

in  the  uterine  region,  and  internally,  tenderness  on  pressure 
nearly  over  the  "whole  abdomen,  but  especially  at  its  lower  part ; 
a  quick,  hard  pulse  ;  and,  in  fact,  all  the  symptoms  of  metritis. 
These  symptoms  were  subdued ;  the  discharge  appeared  to  be 
entirely  arrested,  but  it  again  returned  in  a  few  weeks.  In 
another  case  he  merely  used  the  injection  of  warm  water;  is 
produced  the  same  symptoms  of  uterine  inflammation,  though  not 
so  severe.  The  patient  had  no  return  of  the  disease.  In  two 
cases,  reported  by  Dr.  Balbirnie,  in  Mr.  Tealier's  practice, 
injections  of  Wood  Soot,  a  handful  to  a  pint  of  Water,  were  used 
at  intervals,  in  one  case,  for  fifteen  days,  in  the  other  for  three 
weeks;  these  injections  were  not  followed  by  any  inflammatory 
symptoms,  and  the  patients  were  entirely  relieved. 

549.  In   some   cases  of  this  disease  the  use  of  the  irritating 
plaster  will  be  attended  with  much  benefit.     If  there  is  tenderness 
on  pressure  over  the  lumbar  or  sacral  regions  of  the  spinal  cord, 
it  should  always  be  used  until  this  is  removed,  providing  there  is 
nothing  to  centra-indicate  its  use ;  and  if  there  be  continued  pain 
and  tenderness  in  the  hypogastric  region,  it  should  be  used  there 
in  the  same  manner. 

PHYSOMETBA,  OR  TYMPANITIS  UTERI. 

550.  This  is  a  very  rare  disease,  and  in  its  description  I  will 
have  to  depend  entirely  upon  continental  authorities,  as  I  have 
never  seen  a  case  of  the  kind,  nor  has  there  been  a  case  reported 
in  the  journals  that  I  am  aware  of.     The  disease  consists  in  an 
accumulation  of  gas  in  the  uterine  cavity,  which  is  supposed  to 
arise   from   chemical  or  putrefactive  changes  in  some  substance 
retained  within  the  uterus.     Dr.  Gooch  describes  twro  forms  of 
this  disease :  in  one  the  air  is  formed  in  the  cavity  of  the  uterus, 
is    retained   for    several    months,    distends    it    to    a   considerable 
magnitude,  and  is  then  expelled  ;  of  this  kind  he  had  never  seen 
an  instance.     In  the  other  form,  the  air  is  formed  in  the  organ, 
but,  instead  of  being  retained,  so  as  to  distend  the  uterus,  it  is 
expelled  with  a  noise  many  times  a  day.     To   prove   that  this 
escape  of  gas  was  from  the  uterus,  he  reports  the  following  case  : 
the  patient  was  subject  to  this  infirmity  only  when  not  pregnant, 


280  DISEASES      OF      WOMEN. 

but  she  was  a  healthy  and  breeding  woman,  and  the  instant  she 
became  pregnant,  her  troublesome  malady  ceased.  She  continued 
entirely  free  from  it  during  her  whole  pregnancy :  but  a  few 
weeks  after  her  delivery  it  returned. 

551.  Boivin  and  Duges  state  that  they  have  never  known  the 
existence  of  an  aeriform  body  in  the  uterus,  except  in  obstetric 
cases,  as  in  retention  of  the  membranes,  or  of  portions  of  the  dead 
foetus,  or  of  putrid  coagula,  causing  gaseous  exhalations,  found  in 
the  iiterus  after  death,  or  escaping,  per  vaginam,  during  life.     In 
such  cases,  the  uterus  may  project,  more  or  less,  into  the  hypo- 
gastric  region,  and  into  the  vagina,  being  resonant  on  percussion, 
and  constituting  a  tumor  circumscribed  and  proportionate  to  the 
quantity  of  gas  it  contains, — this  quantity  varying,  especially  with 
the  degree  of  inertia  of  the  uterus. 

552.  Other  cases  have  been  reported  in  which  the  accumulation 
of  gas  in  the  uterine  cavity  appeared  to  be  the  result  of  a  morbid 
exhalation,  or  secretion,  and  not  by  chemical  changes.     A  case 
of  this  kind   came  under  the  observation  of  Mr.  John  Hunter, 
which  he  endeavored  to  elucidate,  but  failed;    on  examination 
after  death  he  could  not  discover  any  disease,  either  of  the  uterus 
or  vagina. 

553.  There  is  no  doubt,   however,  that  physometra,    in   the 
majority  of  cases,  is  the  result  of  a  chemical  decomposition  of 
some  substance  retained  within  the  cavity  of  the  uterus.     Thus  it 
may  arise  after  labor  from  retention  of  the  membranes,  or  a  por- 
tion of  the  placenta,  or  of  a  dead  foetus,  or  in  some  rare  cases,  of  a 
retention  of  the  lochial  discharge.     At  other  times  it  may  arise 
from    decomposition   of  retained   secretions,    as  of    the   uterine 
mucus,  coagula  resulting  from  menorrhagia,  or  even  of  the  cata- 
menia;    or  of  the  chemical  decomposition   of  a  polypus,  moles 
hydatids,  etc.     Boivin  and  Duges  report  three  cases  illustrative 
of  the  origin  of  this  disease.     In  the  first  case  the  eatamenia  were 
checked  by  exposure  to  cold,  followed  by  pains  and  swelling  of 
the  uterus,  which  extended  to  the  umbilicus,  and  was  resonant  on 
percussion,  with  remittent  fever.     The  finger  was  carried  as  far 
as  the  os  uteri,  upon  which  a  portion  of  fetid  gas  immediately 
escaped ;    the   abdomen   collapsed,   but   soon   became    distended 


T  Y  M  P  A  X  I  T  I  S     UTERI.  281 

anew  :  a  tube  was  introduced  into  the  uterus,  in  order  to  apply 
fumigations,  gas  issued  copiously,  coagula  followed,  and  the 
patient  was  cured.  In  the  other  two  cases,  who  had  been  affected 
a  long  time  with  pains  in  the  uterus,  and  fetid,  aeriform  exhala- 
tions, the  uterus  was  found  to  be  filled  with  putrid  effluvia  :  its 
interior  surface  was  ulcerated,  and  the  os  uteri  closed  by  the 
swelling  of  its  borders. 

554.  Symptoms. — According  to  M.  Colombat,  the  symptoms  of 
physometra  consist  in  a  feeling  of  uneasiness  and  tension  in  the 
hypogastric  region  ;  the  woman  complains  of  a  pain,  beginning  in 
the  womb,  and  running  off  towards  the  groins,  loins,  thighs,  and, 
in   some  instances,  even   to   the  diaphragm.     In  most  cases   the 
menses  are  suppressed,  yet  there  are  some  women  who  continue 
to  have  them  regularly.     The  abdomen,  which  enlarges,  presents 
a  uniform,  circumscribed  tumor,  tense,  and  resounding  upon  per- 
cussion like  a  drum.     The  womb,  which  gradually  rises  above  the 
pubis,  tends  towards  the  umbilicus,  and  may  even  reach  above  it, 
but  does  not  increase  in  weight,  though  having  acquired,  as  in 
many  instances,  considerable  magnitude.     This  evolution  is  some- 
times accompanied  with  thirst,  anorexia,  rigors,  and  slight  fever, 
increasing  generally  towards  evening  ;  the  excretions  of  stool  and 
urine  are  more  or  less  disordered ;  the  patient  has  some  respira- 
tory uneasiness,   becomes   inactive,   dislikes   to  move,  and  it  is, 
indeed,  not  uncommon  for  the  uterine  distention  to  excite  sympa- 
thetic action  of  the  breasts,  and  even  secrete  a  sort  of  milky  fluid. 

555.  In   this   state   of  things,   the   expulsion  of  a  portion  of 
gas    from    the    vulva   gives    relief,   and,    generally  speaking,    an 
abundant  discharge  of  it,  which  is  commonly  accompanied  with 
noise,  dissipates  all  the  symptoms  of  the  malady.     This  sort  of 
uterine  eructation  may  happen  at  very  various  periods ;  it  is  rare, 
however,  for  the  gas  to  be  retained  within  the  womb  beyond  five 
or    six   months.     Under    such    circumstances,    the    menses    not 
returning,  the  woman  is  apt  to  suppose  herself  pregnant,  and  the 
more  so,  as  the  feelings  she  experiences  resemble  those  occurring 
in  pregnancy. 

556.  Diagnosis. — This  disease  may  be   readily  distinguished 
from  pregnancy  by  the  resonance  of  the  tumor,  by  the  lightnesa 


282  DISEASES     OF    WOMEN. 

of  the  uterus  when  it  is  elevated  upon  the  finger,  and  by  the 
absence  of  fetal  movement,  and  the  evidence  furnished  by  ballot- 
tement,  ausculation,  etc.  From  all  other  diseases  of  the  uterus 
by  the  resonance  of  the  tumor,  which  may  be  ascertained  to  be 
the  uterus  by  the  vaginal  and  hypogastric  touch,  and  by  the 
lightness  of  the  uterus. 

557.  Treatment. — The  first  object  of   the  practitioner  in  this 
disease  is  to  remove  the  accumulation  of  gas  in  the  uterine  cavity. 
For   this   purpose  a  small  cannula  may  be  introduced  into   the 
cavity  of  the   uterus,  in  the  same  manner  that  we  introduce  the 
uterine  sound  ;  as  soon  as  the  cannula  is  introduced,  the  gas  will 
escape,  and  the  abdomen  rapidly  collapse.     (See  report  of  a  case 
by  Prof.  Bedford,  Clinical  Lectures,  p.  322.)     After  the  evacua- 
tion of  the  gas,  such  measures  should  be  employed  as  will  remove 
the   producing  cause,  the  putrefactive    substance   in  the  uterine 
cavity.     For  this  purpose  we  may  use  injections  of  warm  water 
into  the  uterine  cavity,  and  if  no  symptoms  of  inflammation  arise 
from  it,  we  may  add  to  the  injection  the  Liquor  Sodae  Chlorinata, 
gradually  increasing  the  strength  of  the  injection.     This  injection 
might  be  replaced  by  an  injection  of  an  infusion  of  the  Baptisia 
Tinctoria,  or  a  very  weak  solution  of  the  Pyroligneous  Acid. 

558.  The  internal  treatment  should  be  directed  to  the  restora- 
tion of  the  general  health,  and  to  stimulate  the  excretory  organs 
to  throw  off  any  morbid  material  that  may  have  been  absorbed 
into  the  system. 

HYDROMETKA — UTERINE  DROPSY. 

559.  This  is  also  a  very  rare  disease,  and,  consequently,  its 
pathology  is  not  well  known.     It  consists  of  an  accumulation  of 
fluid  within  the  cavity  of  the  uterus,  which  is  retained,  either 
from  inertia,  or  from  some  morbid  change- in  the  structure  of  the 
organ.     This   accumulation   may   consist   of  a   serous  fluid,    of 
mucus,  pus,  or  of  a  dark,  sero-sanguineolent  fluid. 

560.  Frank  describes  four  varieties  of  this  disease.     1.  The 
cellular,  when  the  effusion  is  immediately  underneath  the  mucous 
membrane  of  the   uterus.     2.  The  independent,  the  fluid  being 


UTERI XE     DROPSY.  283 

in  the  uterine  cavity.     3.   The    hydatic.      4.    Hydro-pliysometra, 
where  both  fluid  and  air  arc  contained  within  the  womb. 

561.  AVe  have  already  seen  that  internal  metritis,  or  uterine 
catarrh  sometimes  gives  rise  to  this  disease,  by  causing  an  abnor- 
mal   contraction    of   the    os    intcrnum    of    the     cervix,    and    the 
consequent  accumulation  of  the  secretion  of  the  inflamed  mucous 
membrane    of    the    uterine    cavity.     As    the    retained    secretion 
increases  in  quantity,  the  uterus  becomes  dilated,  and  its  mucous 
membrane    changes    its    character    to   a   thin,    serous  membrane, 
secreting  a  colorless,  serous,  albuminous  fluid,  resembling  synovia. 
In  this  case,  the  increase  in  the  size  of  the  uterus  is  mostly  at  the 
the  expense  of  the  thickness  of  its  walls,  the  uterus  becoming  a 
slightly  thickened  hydropic  capsule  ;  or  the  uterine  tissue  may 
preserve  its  normal  character,  the  evolution   taking  place  in  the 
same  manner  that  it  does  in  pregnancy,  the  contained  fluid  being 
hemorrhagic  in  character,  or  consisting  of  a  purulent  or  muco- 
purulent    secretion.     Boivin    and    Duges    state    that    they    have 
observed  it  in  a  case  of  cancer  of  the  uterus  ;  it  would  recur  for 
a  short  time,  and  then  disappear  by  copious  evacuations.     They 
have,  also,  seen  it  follow  chronic  metritis,  presenting,  on  examina- 
tion   after    death,   the    cavity   of   the    uterus   filled  with  a  large 
quantity  of  pus,  and  the  os  uteri  obliterated  by  adhesions.     The 
sero-mucous  fluid  secreted  by  the  mucous  membrane  of  the  uterus 
is  almost  always  mixed  with  blood  or  pus.     The  uterus  is  seldom 
found  merely  thinned  and  distended  in  these  cases  ;  the  tissue  is 
most    commonly    beset   with    scirrhus,    ulcerations,  hydatids,    or 
polypi ;  and  the   os  uteri  is  sometimes   obstructed  by  a  tumor, 
sometimes  merely  closed  by  tumefaction. 

562.  Causes. — Inflammation  of  the  uterus  may  be  said  to  be 
the  most  frequent  cause,  though  it  has  been  attributed,  by  some 
authors,  to  constitutional  debility. 

563.  Symptoms. — According  to  M.  Colombat,  the  size  of  the 
abdomen  increases,  with  more  or  less  rapidity,  and  the 'swelling, 
which  commences  in  the  middle  of  the  hypogastrium,  gradually 
extends  from  below  upward.     During  the  first  months,  the  woman 
supposes  herself  pregnant ;  the  breasts  either  lessen   or  increase 
in  size  ;  the   countenance,  which  is  bloated  and  pale,  bears  tho 


28-4  DISEASES     OF      TTOMEX. 

impress  of  languor  ;  she  has  a  feeling  of  weight  in  the  pelvis, 
pains  in  the  loins,  dragging  sensations  in  the  groins,  and  some- 
times a  slight  degree  of  fever.  By  palpation,  we  discover  a 
rounded  and  firm  tumor  in  the  hypogastrium,  which  appears  to 
come  up  from  the  pelvis,  to  a  certain  hight,  greater  or  less.  The 
position  of  this  tumor  is  very  little  changed  by  the  changes  of 
the  woman's  position,  and  we  find  a  deep-seated,  obscure,  circum- 
scribed fluctuation  in  it.  But  the  least  equivocal  sign  is  that 
ascertained  by  touching  ;  in  fact,  by  introducing  a  finger  into  the 
vagina  as  far  as  the  cervix  uteri,  and  then  pressing  the  tumor 
with  the  other  hand,  we  readily  feel  the  shock  of  a  fluid,  and 
a  very  distinct  fluctuation.  This  is  not  a  symptom  of  ascites,  nor 
of  dropsy  of  the  ovaria  or  tubes,  for,  in  those  affections,  the 
cavity  of  the  uterus  is  not  distended  with  fluid,  but  the  organ  is 
itself  jammed  down  toward  the  bottom  of  the  pelvis,  without  any 
increase  of  size. 

564.  The  menses  are  nearly  always  suppressed,  though,  accord- 
ing to  some  authors,  there  are  some  exceptions.     If  the  disease 
continues  for  any  length  of  time,  the  general  health  will  suifer 
more  or  less,  the  appetite  will  become  impaired,  and  symptoms 
of   dyspepsia  manifest  themselves.     In  the   later    stages   of  the 
disease,  the  pulse  will  be  found  small  and  quick,  the  skin  dry  and 
harsh,  the  bowels  irregular,  and  the  urine  passed  in  small  quan- 
tities, and  depositing  a  brick-dust  sediment.     According  to  Dr. 
Churchill,  the  patient  may  die  from  exhaustion,  in  consequence 
of  the  secondary  fever ;  or  the  womb,  unable  to  dilate  more,  or 
weakness  in  some  part  by  previous  or  present  disease,  may  give 
way,  and  the  contents  escaping  into  the  peritoneal  cavity,  fatal 
peritonitis   may  result   immediately.     This   is   the   usual  conse- 
quence of  obliteration  of  the  canal  of  the  cervix  in  old  women. 

565.  Diagnosis. — Owing  to  the  cessation  of  the  menses,  and 
the  subsequent  enlargement  of  the  abdomen,  hydrometra  will  be 
more  liable  to  be  mistaken  for  pregnancy  than  anything  else. 
We  may  easily  distinguish  it  from  pregnancy,  however,  by  the 
absence  of  the  signs  furnished  by  ballottement,  by  the  stethoscope, 
and  especially  by  the  absence  of  the  foetal  movement. 

566.  It  may  be  distinguished  from  physometra  by  the  dull 


UTEKIXE     DROPSY.  285 

sound  on  percussion,  and  by  the  increased  weight  of  the  uterus. 
From  ascites  and  ovarian  disease  by  the  results  of  the  hypogas- 
tric  and  vaginal  touch.  By  this  means  we  may  ascertain  the 
exact  extent  of  the  enlargement,  and  that  it  is  due  to  an  increase 
in  the  size  of  the  uterus.  From  tumors  of  the  uterus  by  the 
fluctuation  and  softness  of  the  enlargement. 

567.  Treatment. — Our  first  object  when  called  to  a  case  of  this 
kind,  is  clearly  to  evacuate  the  contents  of  the  uterus.     To  effect 
this,  it  has  been  recommended  to  use  errhines  to  produce  severe 
sneezing,  or  emetics  to  produce  vomiting,  thereby  causing  a  severe 
and  sudden  contraction  of  the  abdominal  muscles;  the  object  pro- 
posed to  be  accomplished  by  this  means,  is  to  give  a  sudden  shock 
to  the  system,  and  cause  severe  compression  of  the  uterine  tumor, 
by  which  its  contents  may  be  expelled.     This  may  b«e  first  tried, 
though  it  has  rarely  proved  successful.     The  easiest  and  quickest 
method  of  evacuating  the  contents,  is  by  the   introduction   of  a 
small  cannula  or  catheter,  which  should  be  allowed  to  remain  until 
all  the  fluid  is  evacuated.     If  there  exists  an  unnatural  degree  of 
contraction   which   prevents   the   passage   of  the    canula,  but  the 
canal  of  the  cervix  is  still  pervious,  we  may  dilate  it  sufficiently 
by  the  use  of  the  sponge-tents  heretofore  described,  to  admit  the 
passage  of  a  tube  of  sufficient  size. 

568.  Should  the  canal  of  the  cervix  be  impervious,  we  have  no 
other  means  of  relieving  the  patient  but  by  puncturing  it,  and 
thus   evacuating   the    fluid.     Where  we    have    to    resort   to    this 
measure,  the  puncture  should  be  made,  if  possible,  in  the  course 
of  the  canal  of  the  cervix  ;    a   common  trocar   will  be  found  as 
good  an  instrument  as  can  be  employed  in  this  case,  leaving  the 
cannula  in  the  puncture  until  the  fluid  is  evacuated.     The  artificial 
opening  made  should  be  kept  pervious,  by  the  occasional  passage 
of  a  bougie.     The  danger  to  be  apprehended  from  this  operation, 
is  subsequent  metritis ;  this  should  be  watched  for,  and  on  its  first 
appearance,  subdued  by  appropriate  treatment. 

569.  The   uterus    has    been    punctured    in   other  places    than 
through  the  cervix.     Thus,  Francis  Wirer  performed  the  opera- 
tion successfully,  by  passing  the  trocar  an  inch  and  a  half  above 
the  pubis,  and  at  the  same  distance  from  the  linea  alba.     Fifty- 


286  DISEASES     OF    WOMEN. 

three  pounds  of  a  thick,  blackish,  bloody  liquid  escaped  through 
the  canula;  steady  pressure  was  afterward  kept  up  with  Munro's 
bandage  and  several  napkins;  the  patient,  who  was  fifty  years  of 
age,  was  completely  cured ;  for  ten  months  after  the  operation 
there  was  no  return.  The  puncture  has  also  been  performed 
through  the  uterine  wall  from  the  vagina ;  there  could  be  no 
object  in  this,  however,  without  there  was  displacement  of  the 
uterus,  the  cervix  being  carried  out  of  reach,  and  could  not  be 
brought  down. 

570.  As   soon  as  the   uterus  has    been    evacuated,   a  bandage 
should  be  placed  around  the  abdomen,  with  a  compress  over  the 
uterus ;  it  might  be  well  too,  to  use  an  injection  into  the  uterine 
cavity,  as  was  spoken   of  under  the  head  of  physometra;  this, 
however,  would  depend  upon  the  condition  of  the  patient,  and  the 
character  of  the  fluid  evacuated.     At  any  rate,  the  vagina  should 
be  frequently  washed  out  with  injections  of  water,  and  the  canai 
of  the  cervix  kept  open  by  occasionally  passing  a  bougie.      As 
the  disease  most  frequently  arises  from  metritis,  the  same  treat- 
ment  should  be   pursued  that  has   been  recommended    for    that 
affection. 

MOLES — HYDATIDS. 

571.  Under  this  head,  we  have  to  consider  a  morbid  mass  in 
the  cavity  of  the  uterus,  arising  from  a  blighted  or  false  concep- 
tion.    The  term  mole,  or  spurious  mole,  has  also  been  applied  to 
almost  any  foreign  body  existing  in  the  cavity  of  the  uterus,  as 
the  remains  of  the  placenta  after  delivery,  to  the  tough  tenacious 
coagula,   which  is  sometimes  formed    from  the  catamenia,  or  in 
menorrhagia,  etc. 

572.  Boivin   and  Duges  admit  of   three  kinds   of  mole:    1. 
Blighted  conception,  or  the  false  germ.     2.  The  fleshy  mole.     3. 
The  hydatid  mole.     Within  these  limits,   they  will  always   be  a 
faulty  product  of  conception,  and  their  origin,  necessarily,  a  con- 
sequence of  impregnation. 

573.  I.    Blighted,    or    False    Conception,    according    to    Dr. 
Churchill,  is  not  intended  (as  has  been  supposed)  to  signify  any 
imperfection  in  the  act  of  generation,  but  merely  that  the  vitality 
of  the  foetus  having  been  destroyed,  the  object  of  utero-gestation 


MOLES HYDATIDS.  287 

has  failed.  In  most  of  these  blighted  ova,  the  foetus  is  altogether 
wanting,  having  been  dissolved  in  the  liquor  amnii ;  we  may,  how- 
ever, generally  discern  the  remains  of  the  umbilical  cord  attached 
to  some  part  of  the  inner  surface.  In  addition,  the  membranes 
(chorion  and  amnion,)  may  be  traced  with  the  placental  develop- 
ment on  some  portion  of  the  periphery  of  the  ovum.  Still,  the 
whole  mass  will  be  found  a  good  deal  changed  in  size,  form  and 
structure,  by  the  effusion  of  blood,  and  the  formation  of  coagula 
between  the  membranes,  or  in  the  placenta,  by  decomposition  of 
lymph,  and  sometimes  by  apparently  quite  new  and  perfect  layers 
of  membrane.  It  is  these  very  changes  which  probably  caused 
the  death  of  the  foetus.  We  can  easily  comprehend  how  very  frail 
the  tenure  of  life  must  be  at  an  early  period ;  we  see  it  broken 
by  mental  or  bodily  shocks  ;  by  vascular  or  nervous  irregularity; 
and  by  any  deviation  from  normal  structure,  such,  for  instance,  as 
a  tumor  at  the  root  of  the  cord,  or  the  cord  being  inserted  where 
*he  flocculi  of  the  chorion  are  deficient,  or  into  a  part  where  the 
placenta  is  not.  In  this  state,  it  is  seldom  retained  for  more  than 
two  or  three  months,  but,  if  not  expelled,  it  may  degenerate  int  • 
a  fleshy  mole.  It  is  not  easy  to  distinguish  a  blighted  ovum 
which  has  been  retained  in  the  womb,  from  a  recent  abortion, 
as  in  the  latter,  the  foetus  may  be  wanting." 

574.  II.  The  fl&shy  mole  is  considered  by  most  authors  to  arise 
from   a  false   conception,    the    ovum   remaining   attached   to   the 
uterus,  and  receiving  and  appropriating  the  blood  destined  for  the 
foetus,  it  increases  in  size  and  density.     Two  forms  of  the  fleshy 
mole  is  described;  in  one  they  are  hollow,  possessing  a  distinct 
lining  membrane,  in  which  are  the  remains  of  the  liquor  amnii. 
The  other  forms  a  solid  fleshy  mass. 

575.  According  to  Boivin  and  Duges,  the  cavity  of  the  fleshy 
mole  is  always  inconsiderable  in  proportion   to   the  substance  of 
its  parieties.     The  fleshy  substance  is  of  unequal  thickness,  of  a 
red  color,  compact,  fungous,   resembling  the   placenta  in  tissue, 
though  more  elastic,   and   less  filamentous.       They  constitute   a 
mass  of  somewhat  rounded  or  oval  form,  uneven,  and  of  a  volume 
varying  from  that  of  a  large  egg  to  that  of  the  head  of  an  infant. 
In  some  instances,  portions  of  a  foetus  have  been  found  either  in 


288  DISEASES     OF     WOMEN. 

the  cavity,  or  imbedded  in  the  substance  of  its  walls.  The  solid 
fleshy  mole  presents  the  same  character  as  the  other;  it  has  no 
central  cavity,  and  is  generally  larger  and  more  misshapen. 

576.  There  is  generally  but  one  mole  present  in  the  uterus  ;  it 
nay,  however,  be  present  with  a  healthy  ovum,  for  it  is  said  to  be 
very  uncommon  for  both  the  products  of    conception  in  a  twin 
pregnancy  to  be  affected  at  the  same  time,  and  for  two  moles  to 
be  formed  in  the  uterus  at  the  same  time.     On  the  contrary,  a 
mole  has  often  been  found  to  exist  with  a  living  foetus,  the  mother 
going  her  natural  time,  the   mole  being  expelled  immediately,  or 
in  two  or  three  days  after  the  birth  of  the   child.     The  existence 
of  a  mole  in  twin  pregnancy  has  often  been  followed  by  abortion, 
the  foetus  and  mole  being  expelled  together ;  or  what  is  still  more 
rare,  the  mole  has  been  expelled  some  time  during  pregnancy, 
the  woman   reaching  her  full  term,  and  giving  birth  to  a  healthy 
child. 

577.  III.  Hydatids,  or  Vesicular  Moles. — This  degeneration  of 
the  ovum  has  been  more  closely  observed,  and  its  pathology  is 
therefore  better  known.     A  probably  not  unfrequent   cause  of 
abortion  is  a  "degeneration  of  the  villi  of  the  chorion  into  pedun- 
culated  vesicles  or  cysts :  the  formation  of  these  cysts  in  the  villi 
lead  to  the  wasting  of  the  parts  around  it,  and  the  consequent 
destruction  of  the  ovum.     These  cysts  are  found  not  only  on  the 
surface    of   the  chorion,  but    the    same   degeneration   also   takes 
place  in  the  placenta.     Mr.  Paget  has  well  described  these  forma- 
tions;    he  says:   "A  part,  or  even  the  whole  of  the  chorion,  is 
covered  with  pellucid  vesicles  Avith  limpid  contents,  borne  on  long, 
slender,   and  often   branching    pedicles.     The   cysts    are  usually 
oval  or  pyriform ;  their  walls  are  clear,  or  have  minute  or  opaque 
dots ;  they  may  be  simple,  or  may  bear  others  projecting  from 
their  walls."    The  whole  process  of  their  formation  may  probably 
be  thus  described  :  "  Certain  of  the  cells  in  the  proper  villi  of  the 
chorion,  deviating  in  their  cell-form,  and  increasing  dispropor- 
tionately in    size,  form    cysts,  which    remain    connected    by  the 
gradually  elongated  and  hyperfcrophied  tissue  of  the  villi.      On 
the  outer  surface  of  the  new-formed  cysts,  each  of  which  would, 
as   it  were,  repeat  the  chorion,  and   surpass  its  powers,  a  new 


MOLES — HYDATIDS.  289 

vegetation  of  villi  sprouts  out  of  the  same  structure  as  the  proper 
villi  of  the  chorion.  In  these  begins  again  a  similar  development 
of  cysts,  and  so  on  ad  infinitum.  Each  cyst,  as  it  enlarges,  seems 
to  lead  to  the  wasting  away  of  the  cells  around  it ;  and  then, 
moving  aAvay  from  the  villus  in  which  it  was  formed,  it  draws  out 
the  base  of  the  villus,  which  strengthens  itself,  and  forms  the 
pedicle  on  which  the  cyst  remains  suspended." 

578.  Boivin  and  Duges  describe  three  forms  of  this  hydatid  or 
vesicular  mole.     1.    The  vesicular  mole  containing  the  embryo. 
2.    The  hollow  vesicular  mole.  *  And,  3.    The  clustered  vesicular 
mole.     The  entire  three  varieties,  however,  have  the  same  forma- 
tion,   and  the    difference  is  not    sufficient   to   justify   a  separate 
description. 

579.  The  quantity  of  these  cysts  contained  in  the  uterus  varies 
very  much.     When  their  formation  commences  it  generally  con- 
tinues until  the  ovum  is  expelled,  so  that,  if  it  is  retained  in  the 
uterus  a  considerable  length  of  time,  the  quantity  might  be  very 
large.    The  cysts  vary  in  size  from  a  pin's-head  to  a  grape  ;  they 
may  be  found  singly  or  in  groups,  in  this  latter  case  resembling  a 
bunch  of  grapes  ;  their  form  is  generally  oval,  though  they  may 
be  elongated  or  round ;  the  contained  fluid  is  generally  transpa- 
rent and  clear,  though  in  the  larger  ones  it  is  often  of  a  straw- 
color  ;  both  white  and  red  vessels  may  be  seen  running  on  their 
surface. 

580.  Symptoms. — The   symptoms  for  the  first  three   or   four 
months  are  the  same  as  in  pregnancy,  suppression  of  the  menses, 
swelling  of  the  breasts,  morning  sickness,  etc.     It  is  only  about 
the  period  when  the  foetal  movements  should  take  place  that  doubt 
arises.     At  this  time,  the  abdomen  is  frequently  much  larger  than 
it  should  be  in  natural  pregnacy,  and  the  constitutional  suffering 
much  greater.     In  regard  to  the  increased  size  of  the  abdomen, 
when  containing  a  mole,  Dr.  Ashwell  remarks  :  —  "  Thus,  if  half 
the  term  has  passed,  the  bulk  may  equal  that  of  a  pregnancy  near 
at  its  close,  and  the  greater  part  of  this  vast  increase  may  have 
occurred  within  a  few  weeks.     If  a  medical  opinion  is  now  asked, 
additional   reasons    for    suspicion   will  now   be   discovered.     The 
stethoscope  will  fail  to  detect  the  pulsations  of  the  foetal  heart,  or 

19 


290  DISEASES     OF     WOMEN. 

even  the  placental  murmur;  there  will  be  no  balancing  the  uterine 
contents  by  ballottement ;  and  the  uterus,  although  greatly  dis- 
tended, will  be  soft  and  doughy  in  feel,  exceedingly  unlike  the 
firm  structure  of  the  impregnated  organ." 

581.  Sometimes  the  presence  of  moles  occasions  considerable 
aggravation  of  the  symptoms  of  pregnancy  ;  the  uterus,  larger  in 
size,  occasions  more  uneasiness  from  its  weight,  especially  if  the 
increase  in  size  has  been   rapid;  the  patient  suffers  more  from 
pains  in  the  loins,  from  disuria,  and  from  lassitude,  than  in  an 
ordinary  pregnancy  ;  there   is   often  a  degree  of  general  illness 
rare   in  natural  gestation.      Sometimes    there   is   a    sanguineous 
discharge  for  sometime  before  the  mass  is  expelled. 

582.  According  to  M.  Colombat,  where  the  mole  has  attained 
its  maturity,  which  is  generally  the  case  from  the  fourth  to  the 
seventh  month,  the  patient  suffers  pains  like  those  of  real  labor ; 
the  womb  contracts,  its  orifice  becomes  dilated,  and  the  mass  is 
expelled.     The  breasts  then  fill  with  milk,   the  lochia  follow  in 
course,  and  all  the  other  secondary  symptoms  take  place  as  in  a 
common  lying-in.     In  a  majority  of  cases  the  expulsion  of  the 
mole  is  followed  by  considerable  flooding,  and  should  its  expulsion 
be  difficult  from  its  attachment  to  the  uterus,  the  hemorrhage  may 
become  very  alarming. 

583.  Diagnosis. — As  this  disease  simulates  pregnancy,  we  have 
first  to  note  the  differences  between  the  two.     In  moles  we  have 
the  absence  of  ballottement,  of  quickening,  and  of  the  stethoscopic 
signs,  —  the  beating  of    the  foetal  heart,  etc. — while     there   is 
generally  a  disproportion  between  the  size  of  the  tumor  and  the 
period  since  it  was  first  observed.     It  may  be  distinguished  from 
physometra,    by   the   absence,    and   the   greater  weight   of  the 
uterus.     From  hydrometra,  by  the  perceptible  fluctuation  in  the 
latter,  and  from  the  greater  accumulation ;  the  diagnosis  is,  how- 
ever, very  difficult,  but  it  is  of  little  importance  from  the  rare 
occurrence  of  hydrometra. 

584.  Treatment  — So  long  as  the  uterus  does  not  contract  upon 
its  contents,  there  is  nothing  to  be  done,  even  if  we  have  ascer- 
tained the  nature  of  the  uterine  contents,  without  there  should  be 
flooding.     In  this  case,  we  should  try  to  arrest  it  by  cold  applica- 


FIBROID     TUMOR.  291 

tions  to  tlie  vulva,  plugging  the  vagina,  and  the  internal  use  of 
the  tincture  of  equal  parts  of  oils  of  erigeron  and  cinnamon.  If 
the  flooding  should  not  cease,  under  the  use  of  these  measures, 
we  would  have  to  excite  contraction  of  the  uterus,  if  possible,  to 
expel  its  contents.  For  this  purpose  we- may  administer  the 
caulophyllin  and  the  ergot,  and  apply  a  bandage  tightly  around 
the  abdomen.  If  the  uterus  does  not  expel  its  contents  under 
the  use  of  these  remedies,  and  the  hemorrhage  continues,  it  is 
advised  to  introduce  the  hand  into  the  uterus,  where  this  can  be 
done,  and  thus  remove  its  contents. 

585.  The  Hooding  that  occurs  after  tlfe  expulsion  of  the  mass 
should  be  treated  in  the  same  manner  as  flooding  after  delivery  ; 
a  bandage   should  be  applied,  and  the  patient   managed  as  after 
ordinary  labor,  but  with  special  reference  to  the  flooding. 

FIBROID  TUMORS. 

586.  Under   this    head   we   have  to  describe  all   those  morbid 
growths  which  have   a  dense,  fibrous  structure,  or  which  in  any 
manner   resemble   fibrous   tissue,  and  are  not   malignant.     These 
growths  may  all  be  arranged  in  two  classes,  the  pediculated  and 
the  non-pediculated.     The  first  are  called  polypi ;  the  second  are 
distinguished  by   the    name    of  fibrous   tumor.     As  pathological 
anatomy  furnishes  the  only  basis  of  a  rational  system  of  practice, 
and  as  this  is  the  only  means  by  which  we  can  obtain  a  know- 
ledge of  any  morbid  process,  the  reader  will  better  understand  the 
nature  of  these  growths,  from  the  following  accurate  description, 
from  Prof.  Rokitansky's  Pathological  Anatomy  : 

587.  "  Anomalous  fibrous   tissue   is  the   most  frequent  of  all 
new  formations  occurring  in  the  uterus,  in  the  shape  of  fibroid  or 
fibrous  tumors.     These  fibroid  growths    of  the    uterus  not  only 
present  all  the  essential  characters  peculiar  to  them  elsewhere,  in 
a  remarkable  degree,  but  they  also  offer  numerous  important  and 
accidental  modifications,  some  of  which  exert  considerable  influ- 
ence   upon    the    uterus.     The    uterus,  as  well   as   the   adjoining 
tissues,  are  particularly  liable  to  be  the  seat  of  fibroid  growths. 
They  not  only  present  all  the  varieties  and  degrees  as  regards 
size  and  volume,  shape,  number,  and  metamorphosis,  but  they  also 


292  DISEASES     OF     WOMEN. 

offer  the  most  various  modifications  in  reference  to  their  seat,  and 
consequent  reflex  action  upon  the  womb. 

588.  "  We  also  find  that  the  changes  of  position  of  the  uterus, 
the  deviations  in  its  shape,  and  of  the  direction  and  form  of  its 

avity,  of  its  size  in  reference  to  the  coexistent  hypertrophy  and 
atropny  of  the  organ,  and  the  relations  of  the  uterine  mucous 
membrane,  etc.,  are  very  remarkable. 

589.  "  The  three  varieties  distinguishable  in  the  fibroid  tumor, 
according  to  its  internal  structure,  are  all  found  in  the  uterus. 
The   variety  in   •which    a   concentric  disposition   of  the  fibers  is 
displayed,  is   here  also  distinguished   by  its  density,  hardness, 
poverty  of  vessels,  smallness,  and  spherical  shape. 

590.  "  The   second  variety,  in  Avhich  the  fibers  appear  irregu- 
larly disposed,  and  issue  from  numerous  centers  or  nuclei,  present 
a  rounded  form,  and  an  uneven,  nodulated  surface,  which  indicates 
the  aggregation  of  the  fibrous  centers  ;    in  reference  to  density 
and  consistency,  vascularity  and  volume,  they  offer  the  extensive 
modifications  already  spoken  of;  they  may,  on  the  one  hand,  be 
very  dense,  and  hard,  and  unvascular;  on  the  other,  in  consequence 
of   an  accumulation  of   cellular  tissue  in  the  interstices  of  the 
fibrous  layers,  they  may  be  more  or  less  vascular  and  succulent, 
or    soft  and   elastic,    soft    and    doughy,    flabby,    etc.,    sometimes 
resembling  a  soft,  mammary  gland,  sometimes  a  coarse-grained 
salivary  gland.     Those  fibroid  tumors,  the  interstices  of  which 
are  dilated  into  cells  or  cavities,  containing  a  serous  fluid,  from 
excessive   exhalation  of  the  intervening    cellular    tissue,    are  of 
extreme    importance.     They    present   fluctuation,    and   may,    on 
account  of  the  deceptive  appearances  accompanying  fibroid  tumors, 
be  easily  mistaken  for  ovarian  dropsy,  hydrometra,  acephalocyst 
of  the  uterus,  or  pregnancy. 

591.  "  The  fibrous  polypus  of  the  uterus,  the  third  variety  of 
fibroid  tumors,  takes  its  origin  by  a  single  or  divided  trunk  in  the 
interstitial  cellular  tissue  of  the  uterine  parenchyma ;  the  former 
expands  into  striated  fasciculi,  which  are  bound  together  by  soft 
or  vascular  and  cellular  interstitial  substance,  and  the  entire  mass 
presents  a  distinctly  lobulated  structure,  which  is  more  or  less 
visible  externally.      The  polypus  grows   into  the  cavity  of  the 


FIBROID     TUMORS. 


293 


uterus,  with  which  it  is  in  the  closest  anatomical  connection,  and 
upon  the  functions  of  which  it  exerts  a  considerable  influence.  It 
enlarges  chiefly  in  one  direction,  and  has  a  cylindrical,  fusiform, 
clubhed,  pyriform  shape,  and  is  more  or  less  flattened  ;  it  is  pro- 
vided with  numerous  and  very  large  vessels,  is  apt  to  swell,  and, 
in  consequence  of  excessive  congestion  and  rupture  of  the  vessels 
we  often  meet  with  extravasation  within  its  tissues. 


FIG.  27. — INTRA-UTERINE  PEDICULATED  FIBROID  TUMOR, — OR  POLYPUS. 
a,  Polypus  drawn  up  with  a  tenaeulum;  b,  its  pedicle;  cc,  the  cavity  of  the  cervix. 

592.    "  The  anatomical  relation  of  fibroid  tumors  to  the  uterine 
•parenchyma  is  very  intimate  in  the  third  variety,  less  so  in  the 


294  DISEASES    OF    W03IEX. 

second,  and  least  of  all  in  the  first,  in  which  the  tumors  adhere  to 
the  uterine  parieties  by  a  thin  layer  of  whitish  or  reddish,  more 
or  less  vascular,  cellular  tissue,  so  that  they  may  be  detached 
without  difficulty. 

593.  "  The  form  of  the  fibroid  tumors  of  the  first  and  second 
variety,  we  have  already  described  as  being  generally  round  ;  in 
the  second  variety  some  alterations  may  occur,  though  the  globu- 
lar form  still  predominates.      The  peculiarities  of  shape  of  the 
fibrous  polypus,  or  third  variety,  have  already  been  stated.     The 
greatest  variety  occurs  in  reference  to  size.     Fibroid  tumors  are 
found  from  the  size  of  a  hemp-seed  to  that  of  a  man's  head. 

594.  "The  fibroid  tumors  belonging  to  the  second  variety  attain 
the  largest  size,  especially  when  of  loose  texture,  and  rich  in 
interstitial  cellular   tissue  ;  the  fibrous  P°Jypi  also  reach  a  con- 
siderable magnitude,  but  the  fibroid  tumors  of  the  first  variety  are 
the  smallest.     They  are   all  generally  developed  slowly,  though 
the    second    and    third   variety  are    occasionally   developed   with 
extraordinary    rapidity ;    they    are    also    liable    to    a    temporary 
increase    of   size    or  tumefaction    proportionate    to    their   vascu- 
larity. 

595.  "  As  to  their  number,  we  sometimes  only  find  a  single, 
sometimes   several   or   many  fibroid   tumors  in  the  same  uterus. 
We  then  observe  tumors  of  the  most  different  sizes  coexisting. 
This  applies  chiefly  to  the  first  two  varieties ;  the  fibrous  polypus 
is  often  solitary,  but  it  also  occurs  in  company  with  the  others. 

596.  "  The  uterine  parieties  are  the  seat  of  the  fibroid  tumors, 
but  not  only  do  they  occur  much  more  frequently  in  the  body 
than  in  the  cervix,  but  in  the  former  they  chiefly  affect  the  upper 
portion  or  fundus.     They  very  rarely  occur  at  the  inner  orifice, 
and,  if  possible,  still  less  frequently  in  the  vaginal  portion.     This 
is  the  case  with  all  fibroid  tumors,  a  fact  that  forms  an  interesting 
contra-distinction  to  the  relation  which  cancerous  disease   bears 
to  the   inferior   segment  of  the  uterus.     Fibrous  polypus,   more 
especially,  is  apt  to  commence  at  the  fundus,  and  at  the  orifices 
of  the  fallopian  tubes.     The  fibroid  tumor  is  inserted  into,  and 
takes  its  origin  from,  the  middle  layers  of  the  uterine  substance, 
or  it  appears  to  be  more  connected  with  the  external  layer,  or 


FIBROID     TUMORS.  295 

even  to  lie  under  the  peritoneum,  or  again,  it  lies  nearer  the  inner 
surface,  or  immediately  under  the  mucous  membrane.  The  first 
two  varieties  are  developed  in  the  most  various  layers,  though 
generally  in  the  external  ones  ;  the  third  forms  upon  the  inter- 
nal layer  exclusively.  The  former  also  very  frequently  present 
other  curious  relations,  whether  they  have  been  developed  in 
the  vicinity  of  the  peritoneum,  or  of  the  mucous  membrane 
of  the  uterus.  In  the  first  instance  the  tumor,  as  it  enlarges, 
gradually  becomes  detached  from  the  uterus,  dragging  the  peri- 
toneum after  it,  and  thus  at  last  becomes  pediculated  or  pen- 
dulous, by  a  peritoneal  cord  of  various  length.  In  the  second 
instance  it  pushes  the  mucous  membrane  before  it,  as  it  enlarges, 
and  at  last  hangs  into  the  uterus  by  a  mucous  pedicle,  thus 
resembling  the  true  fibrous  polypus,  from  which  it  may  be  dis- 
tinguished by  its  relation  to  the  uterine  parenchyma,  and  by  its 
internal  structure. 

597.  "  We  must  here  advert  to  a  circumstance  that  is  not  of 
rare  occurrence, — viz. :  we  sometimes  find  a  fibroid  tumor  in  the 
pelvic    cavity,    and    generally    in    Douglas'    space,    Avithout    any 
further  connection  Avith  the  uterus,   except  by  means  of  cellular 
cords,  or  lamina  of  neAv  formation,  (false  membranes),  Avhich  pass 
from  the  tumor  to  the  uterus  and  its  appendages, — to  the  pelvic 
Avails,  the  rectum,  etc.     The  question  presents  itself,  Avhich  is  the 
original  point  of  development  of  such  fibroid  tumors?     They  are 
generally  tumors  which  have  originally  been  developed  under  the 
uterine   peritoneum,   and,  after    having    become    entangled    in    a 
net-Avork  of  pseudo-membranous    formations,  resulting   from  the 
peritonitis    they  have  excited,  are   gradually  detached  from    the 
uterus.     Occasionally,  however,  they  may  have    been   developed 
within  the  false  membranes  themsehres,  which  is  the  more  pro- 
bable, if  we  consider  that  the  HCAV  tissue,  as  it  proceeds  from  the 
uterine   peritoneum,   participates    in    the    character    of   the    sub- 
serous,  uterine,  cellular  tissue.     Hence,  it  is  extremely  likely  that 
we  really  see  very  small  fibroid  tumors  occasionally  developed  in 
this  new  tissue. 

598.  "  To  these  fibroid   tumors  the  loose  fibrous   concretions, 
which  are  sometimes  found  in  the  pelvic  cavity,  are  allied ;  they 


296  DISEASES    OF     WOMEN. 

must  be  considered  as  fibroid  tumors  of  the  uterus  which  have 
become  detached  in  consequence  of  atrophy  of  the  peduncle. 

599.  "Metamorphoses   and    Diseases   of  the    Uterine    Fibroid 
Tumors — Spontaneous  Cure. — We  have  already  spoken  of  ossifi- 
cation,   congestion,    inflammation,   suppuration,   and    solution    of 
fibroid  tumors  generally ;  and  these  remarks  apply  with  the  more 
force  to  uterine  fibroid  tumors,  as  we  assumed  the  latter  as  the 
foundation  upon  which  we  based  our  observations.     Ossification 
occurs  very  frequently,  congestion  less  so,  and  inflammation  and 
its  terminations,  rarely.     A  spontaneous   cure,  under  which  head 
we  must  also  class  ossification,  on  account  of  the  destruction  of 
vitality  in  the  tumor,  occurs  in  a  few  rare  cases,  by  a  detachment 
of  the  fibroid  tumor  as  it  projects  into  the  uterus,  or  is  suspended 
in  it  by  a  mucous  pedicle.     It  is  effected  in  the  following  manner : 
The  mucous  membrane  of  the  uterus  covering  the  apex  of  the 
tumor  is  in  a  condition  of  permanent  irritation  and  congestion  j 
this    is    at   last    converted   into    inflammation,  and  terminates  in 
suppuration  and  gangrene.     The  tumor  is  thus  partially  exposed 
toward  the  uterine  cavity,  and  the  destructive  process  gradually 
involving  its  entire  cellular  investment,  it  becomes  detached,  and 
passes  through  the  opening  in  the  uterine  mucous  membrane  into 
the  uterine  cavity.     Ancient  and  modern  cases  are  on  record,  in 
which  fibroid  tumors  of  various  sizes,  and  ossified  tumors,  were 
thus  discharged.      The   powers  of  nature   rarely  suffice,  if  the 
tumors    are    of  considerable   size,  as  the    extensive   suppuration 
necessary   for   that    purpose   is   likely  to   prove   fatal,   both   by 
exhaustion  and  by  the  extension  of  inflammation  to  neighboring 
organs.     It  would  appear  that  the  fibrous  polypus  is  occasionally, 
though  very  rarely,  discharged  in  a  similar  manner,  in  conse- 
quence of  suppuration  occurring  at  its  root  and  in  the  surrounding 
tissues. 

600.  "  The  changes  in  the  uterus,  consequent  upon  the  presence 
of  one  or  of  several  large  fibroid  tumors,  are  numerous  and  im- 
portant, by  reason  of  the  diagnostic  characters  they  afford. 

601.  "  In  the  first  instance,  the  volume  of  the  uterus  increases 
in  proportion  to  the  number  and  size  of  the  tumors ;  the  fibrous 
polypus  causes  an  enlargement  of  the  uterine  cavity,  correspond- 


FIBROID     TUMORS.  297 

ing  to  the  size  of  the  polypus.  The  increase  in  the  substance,  the 
hypertrophy  of  the  uterus,  which  the  fibroid  groAvths  generally 
induce,  and,  on  the  other  hand,  the  atrophy  of  the  organ,  are  of 
greater  interest.  The  hypertrophy  appears  as  a  development 
of  the  uterine  tissue,  resembling  that  occurring  in  pregnancy;  it 
varies  in  degree.  In  reference  to  the  latter  subject,  the  question 
presents  itself,  by  what  means  the  different  degrees  of  hypertrophy 
are  determined,  and  on  account  of  the  occasional  passive  condition 
and  the  occasional  atrophy  of  the  uterus,  it  is  necessary  still 
further  to  generalize,  and  to  ask,  how  it  happens  that  under  some 
circumstances  the  uterus  becomes  hypertrophied,  in  others,  remains 
unchanged,  and  in  others,  again,  becomes  atrophied  ?  In  answer, 
we  offer  the  following  remarks  : 

602.  "  1.    The   nearer   the    fibroid    growths    approach    to    the 
uterine  mucous  membrane,  and   project   into    the  cavity  of   the 
uterus,  and  thus  maintain  the  mucous   membrane   in  a  state   of 
irritation  and  inflammation,  the  more  palpable  is  the  hypertrophy 
of  the  uterus.     It   is    most    fully   developed,   so    as  to  resemble 
pregnancy,  in  the  case  of  the  fibrous  polypus. 

"  2.  Hypertrophy  of  the  uterus  appears  to  be  encouraged  by  a 
vascular  state  of  the  tumor,  by  the  latter  being  less  dense  and 
capable  of  rapid  growth. 

"3.  As  also  by  the  development  of  the  tumor,  during  or  shortly 
after  the  period  of  conceptivity. 

"  4.  The  size  of  the  tumor  exerts  no  direct  influence  upon  the 
origin  of  hypertrophy  or  atrophy. 

"  5.  Atrophy  undoubtedly  results  very  rarely  from  fibroid 
tumors,  nor  must  we  forget  that  they  are  not  unfrequently 
developed  in  the  uterus  during  the  period  of  decrepitude,  and  that 
they  increase  very  slowly  on  account  of  the  universal  state  of 
marasmus.  In  this  case  the  atrophy  of  the  uterus  is  entirely 
independent  of,  and  antecedent  to  the  fibroid  tumors.  The 
atrophy  of  the  cervix  accompanying  large  fibroid  growths,  is,  as 
we  shall  have  occasion  to  explain  more  fully,  the  result  of 
mechanical  traction. 

603.  "  An  important  change  takes  place  in  the  position  of  the 
uterus,  which  may  be  discovered  by  external  examination.     Not 


298  DISEASES     OF     WOMEN. 

only  does  a  large  fibroid  tumor  that  occupies  the  external  layer 
of  the  uterine  tissue,  push  the  organ  to  the  opposite  side  of  the 
pelvis,  but  we  also  notice  a  remarkable  ascent  of  the  organ.  The 
more  numerous  and  the  larger  the  tumors  are,  and  the  more  they 
consequently  rise  out  of  the  pelvis,  as  it  interferes  with  their 
growth,  the  more  they  drag  the  uterus  after  them ;  its  vertical 
position  being  also  changed  in  proportion  as  the  fibroid  tumors 
preponderate  on  one  side  or  the  other.  This  traction  necessarily 
causes  an  elevation  and  elongation  of  the  cervix. 

604.  "The  external  surface  of  the  uterus  is,  as  may  be  readily 
understood,  variously  disfigured   by  the   projecting  tumors.     In 
the  same  manner  the  cavity  of  the  uterus,  in  addition  to  a  corres- 
ponding  elongation,   undergoes  various    alterations  in  form  and 
direction,  proportionate  to   the  number  and  size   of  the  tumors 
which  project  internally.     In  reference  to  the  displacement,  we 
sometimes  find  the  entire  cavity  forced  out  of  the  mesial  line ;  at 
others,  it  presents  more   or  less  angular  deflections.     The  most 
important  disfiguration  is  effected  by  the  upward  traction  exerted 
by  numerous  and  large  fibroids.     The  uterus,  and  particularly  the 
cervix,  is  elongated  to  a  degree  proportioned  to  the  degree  of 
traction ;  it  becomes   thinner,  and  the   attenuation  may,  in  rare 
cases,  even  cause  a  gradual   solution  of  continuity,  one  portion 
remaining  attached  to  the  vagina,  another  following  the  upward 
direction  of  the  uterus,  and  the  connection  being  maintained  by  a 
mere  band  of  cellulo-fibrous  tissue.     The  channel  of  the  cervix,  at 
the  same  time,  contracts,  and  may  even  become  entirely  obliter- 
ated.    The  vaginal  portion  gradually  disappears,  the  vagina  itself 
becomes  smooth  and  narrower  in  consequence  of  the  elongation, 
and   its   arch   is    converted   into   a   funnel,  the    apex   of  which 
terminates  in  the  os  uteri. 

605.  "  If  one  or  more  fibroid  growths  occupy  a  lateral  portion 
of  the  uterine  parieties,  and  especially  if  they  be  seated  in  the 
vicinity  of  the  fallopian  tubes,,  the  external  form  of  the  uterus 
may  be    rendered    oblique ;    if,    under    these    circumstances,   the 
tumors  enlarge,  and  consequently  exert  lateral  traction,  this  may 
be  recognized  by  the  elevation 'of  the  corresponding  side  of  the 
os  tineas,  and  the  increased  distention  of  the  vagina. 


FIBROID     TUMORS.  299 

606.  "  Fibrous  polypus  gives  rise  to  a  dilatation  of  the  uterine 
cavity,  and  of  the  cervix,  corresponding  to  the  size  of  the  morbid 
growth ;    if  the  enlargement   proceeds   to  a  greater  extent,  the 
external  orifice  becomes  dilated,  and  the  tumor  projects  through 
it   into   the   vagina.      Large    and    heavy   morbid    masses   of   this 

~  O  */ 

description  frequently  cause  a  slight  descent  of  that  portion  of  the 
uterus  into  Avhich  they  are  inserted,  by  the  traction  which  they 
exert,  and  sometimes  even  induce  complete  inversion  of  the 
womb. 

607.  "  The  mucous  membrane  of  the  uterus  is  more  liable  to 
catarrh  and  blennorrhea,  the  nearer  the  fibroid  tumor  approaches 
to  it ;  sometimes  it  becomes  hyperaemic,  and  blood  is  effused  upon 
it.     This  is  particularly  the  case  with  the  fibrous  polypus,  which 
is   not   only  accompanied  by  the  ordinary  hemorrhage  from  the 
capillaries   of   the  mucous    membrane,  but  also  from  the  larger 
vessels  of  the  uterus,  or  sinuses  of  the  morbid  growth  that  have 
given  way  to  excessive  traction. 

608.  "  Fibroid  tumors  of  the  uterus  scarcely  ever  occur  before 
the  twentieth  year;  a  fact  which  is  established  by  the  numerous 
observations  made  by  ourselves  and  other  anatomists.     They  are 
even  unusual  up  to  the  thirtieth,  and  present  themselves  most 
frequently  shortly  after  the  fortieth  year.     Without  entering  into 
an   analysis  of  the  almost  innumerable   cases  that  we  ourselves 
have  met  with,  we  may  mention  the  results  of  Bayle's  calcula- 
tions as  to  the  frequency  of  their  occurrence.     He  states  that  of 
one  hundred  females   that   die  after  the  thirty-fifth  year  of  life, 
twenty,  at  least,  are  affected  with  fibroid  tumors. 

609.  "They  are  found  in  complication  with  the  most  various 
morbid  growths  of  the  uterus  and  its  appendages  ;  but  especially 
with  cancer   of  the   cervix,  with    the  corroding  ulcer   of  the  os 
uteri,  with  ovarian  dropsy,  etc.;  still,  on  the  whole,  the  complica- 
tion with  cancer  is  not  frequent. 

610.  "The  powers  of  conception  are  commonly  not  impaired 
by  the  presence  of  fibroid  tumors,  and  if  these  are  small,  and  do 
not  occupy  an    unusual  position,  they  have  not  necessarily  an 
injurious  influence  upon  pregnancy  and  parturition,  though  they 
frequently  cause  abortion  and  hemorrhage  after  birth.     Parturi- 


300  DISEASES    OF    WOMEX. 

tion  may  be  very  much  impeded,  if  they  occupy  the  cervix  uteri. 
It  is  important  to  know  that  these  tumors  become  more  vascular,, 
succulent,  and  softened,  during  pregnancy,  and  assume  a  bluish- 
red  color,  so  that  their  original  appearance  is  entirely  changed. 
As  the  uterus  returns  to  its  normal  shape,  the  morbid  growth  also 
resumes  its  ordinary  characters.  Pregnancy  is  even  said  to  give 
rise  to  hemorrhage  and  inflammation  in  the  tissue  of  the  fibroid 
tumor. 

611.  "An  unusual  though  very  important  occurrence,  brought 
on  by  the   excessive    expansion    and    traction   exerted  by  large 
fibroid  tumors,  is  the  laceration  of  the  vessels,  and  especially  of 
the  veins.     We   have  once  observed  the  rupture  of  a  vesical  vein, 
(with  that  of  the  mucous  membrane,)  followed  by  hemorrhage  into 
the  bladder,  and  in  another  case,  the  rupture  of  the  sub-perito- 
neal vein  of  a  fibroid  tumor,  with  hemorrhage  into  the  abdominal 
cavity,  as  described  by  other  writers." 

612.  Symptoms  of  non-pediculated   Fibroid    Tumors. — While 
these  tumors   remain  small,    there   are    no  symptoms  present   to 
mark  the  presence  of  the  disease ;  even  when  the  tumors  are  of 
considerable  size,  the  patients  seldom  complain.     The  symptoms 
that  arise  from  the  presence  of  these  tumors  are  principally  refer- 
able to  the  consequent  displacement  of  the  uterus,  to  pressure  on 
some  adjacent  organ,  and  to  the  increased  weight  of  the  pelvic 
contents. 

613.  The  symptoms  arising  from  displacement  of  the  uterus, 
vary   according    to  the   location  of  the  tumor.      Thus,  if  it   is 
formed  in  the  anterior  wall,  beneath  the  peritoneum,  the  uterus  is 
thrown  backward  against  the  rectum,  and  we  have  all  the  symp- 
toms of  retroversion  of  the  womb ;  if  in  the  posterior  wall  we 
have  anteversion  with  the  symptoms  of  vesical   irritation  conse- 
quent upon  the  pressure  of  the  uterus  upon  the  bladder. 

614.  The  symptoms  arising  from  pressure,  either  of  the  tumor 
or  of  the  enlarged  uterus,  are  not  well  marked,  only  when  this 
pressure  is  against  the   rectum  behind,  or  the  bladder  in  front 
When  the  pressure  is  against  the  rectum,  there  will  usually  be 
obstinate  constipation,  a  sense  of  weight  and  closure  in  that  part, 
there  will  be  much  difficulty  in  passing  the  faeces,  and  there  will 


FIBROID     TUMORS.  301 

generally  be  tenesmus  and  a  constant  desire  to  evacuate  the 
bowels.  If  the  pressure  be  anteriorly  against  the  bladder,  there 
will  be  vesical  irritation,  a  constant  desire  to  micturate,  pains 
along  the  course  of  the  urethra,  etc.;  or  there  may  be  retention 
of  urine,  or  the  irritation  may  extend  to  the  mucous  membrane 
of  the  bladder,  causing  an  increased  secretion  of  mucus. 

615.  When  the  tumors  are  of  considerable  size,  there  is  nearly 
always  a  sense   of  weight  in   the  pelvis,   of  bearing  down,   and 
aching  in  the  loins  and  small  of  the  back.     Sometimes  when  the 
tumor  presses  upon  the  pelvic  nerves,  cramps   of  the   thighs  or 
legs  may  occur,  or  they  may  be  painful,  or  in  rare  cases,  it  might 
give  rise  to  partial  paralysis ;  if  the  pressure  is  against  the  veins 
coming  from  the  lower  extremities,  they  may  become  oedmatous. 

616.  Where  the  tumor  is  situated  on  the  internal  surface  of 
the  uterus,  especially  if  it  projects  into  its  cavity,  it  may  give  rise 
to  hemorrhage.     Hemorrhages  rarely  occur,  so  long  as  the  tumor 
is  not  pediculated. 

617.  These    tumors    sometimes    interfere    with    the  menstrual 
function ;  thus,  cases  have  been  reported,  in  which  the  intervals 
were  shortened,  the  menses  appearing  every  two  or  three  weeks ; 
others  again,  where  the  intervals  were  lengthened,  or  where  tho 
time  was  irregular ;  others  again,  where  the  duration  and  quantity 
of  the  discharge  was  lessened;  but  more  numerous  ones,  where 
both  the  duration  and  the  quantity  were  increased.     Many  cases 
have    been   reported,    where    the    catamenia    were    entirely    sup- 
pressed.    Again,  we  have  reports  of  cases,  where  the  catamenia 
were   retained  from    obstruction   of    the    cervix,    caused   by   the 
enlargement  of  the  tumor. 

618.  If  inflammation  should  arise  either  within  the  tumor,  or 
in  the    uterus   in   consequence   of    it,    the    entire    symptoms    of 
metritis  will  be  present,  as  tenderness  on  pressure  over  the  region 
of  the  tumor,  more  or  less  fever,  gastric  and  intestinal  irritation, 
etc. 

619.  Conception  may,  and  does  frequently  take  place  in  these 
cases ;  utero-gestation  may  go  on  to  full  term,  or  abortion  may 
take  place  at  the  third  or  fourth  month.     No  definite  rule  can  be 
laid  down  in  these  cases ;  even  authors  who  have  closely  observed 


o02  DISEASES     OF     WOMEN. 

them,  differ  widely ;  some  describing  these  growths  as  a  frequent 
cause  of  abortion ;  while  others  contend  that  they  are  not  a 
necessary  cause  of  abortion,  and  that  pregnancy  may,  and  fre- 
quently does,  go  on  to  full  term. 

620.  Fibroid  tumors  of  the  uterus  may  be  a  cause  of  difficult 
labor,   and   may   even   cause    serious   results.     Thus  Boivin    and 
Duges  relate  a  case,  in  which  the  patient  died  after  delivery,  of 
peritonitis,  and  presented,  at  the  parieties  of  the  cervix  uteri,  a 
fibrous  tumor  as  large  as  the  fist ;  the  labor  had  been  protracted 
and   very   painful;   the   head   of   the   child    could    only    pass    by 
becoming  crushed  against  the  parieties  of  the  pelvis.     Another 
case  is  related,  in  which  the  tumor  was  formed  in  the  cervix ;  it 
prevented   delivery   for   thirteen  'days ;    and    another,    in    which 
rupture  of  the   uterus  and  death,  were  occasioned  by  a  similar 
obstacle. 

621.  These  tumors  may  be  a  cause  of  danger  after  delivery, 
the  presence   of  the   tumor  preventing  that  contraction    of    the 
uterus  necessary  to  close  the  orifices  of  the  uterine  vessels,  the 
patients  suffering  from  profuse  hemorrhage.     Two  cases  of  this 
kind,  are  related  by  the  same  authors.     In  the  first,  the  patient 
died  from  hemorrhage,  the   autopsy  revealed  the  presence  of  a 
fibrous  tumor  in  the  posterior  parieties  of  the  organ,  which  pre- 
vented its  contracting  after  delivery.     The  second  case  likewise 
perished  from  hemorrhage;  three  fibrous  tumors  were  found  in 
the  body  of  the  uterus,  the  largest  of  which,  was  ten  inches  in 
breadth  in  one  direction,  and  five  in  the  other. 

622.  Diagnosis. — The  diagnosis  of  these  tumors  will  have  to 
be  effected  by  a  careful  examination  of  the  uterine  organs.    Thus, 
if  the  enlargement  can  be  felt  through  the  abdominal  parieties, 
we  may  gain  some  information  from  its  hardness ;  by  introducing 
a  finger  into  the  vagina,   and  elevating  the  uterus  upon  it,  we 
may  ascertain  whether  or  not  it  is  connected  with  this  organ. 
The  most  reliable  information,  however,  may  be  gained  by  the 
use  of  the  uterine  sound.     Thus,  if  it  passes  into  the  cavity  of 
the  uterus  only  two  inches  and  a  half,  we  have  ascertained  that 
the  cavity  of  the  uterus  is  not  enlarged,  if  the  tumor  project  into 
the   cavity  it  may  be  detected  by  the  sound;  by  grasping  the 


FIBROID     TUMORS.  303 

tumor  with  one  hand  and  moving  the  uterus  away  from  it,  we  may 
ascertain  whether  or  not  it  is  connected  with  that  organ,  etc.  (See 
Uterine  Sound.) 

G23.  From  congestion  and  induration  of  the  uterus,  by  their 
insensibility  on  pressure,  and  by  their  being  well  defined  and 
hard,  while  the  uterus,  in  a  state  of  congestion,  is  very  sensitive, 
and  the  enlargement  is  diffused.  From  scirrhus  or  carcinoma,  by 
the  absence  of  the  pain,  hemorrhage,  fetid  discharge,  etc.,  which 
characterize  malignant  disease,  and  by  the  better  defined  character 
of  the  fibroid  tumor,  and  generally  by  its  greater  volume. 

624.  From  polypus  uteri,  Dr.  Churchill  states,  that  there  will 
be  little  or  ho  difficulty  in  distinguishing  these  two  diseases,  if  the 
fibrous  tumor  be  situated  in  the  parieties  of  the  upper  part  of  the 
uterus,  by  its  defined  shape  and  prominence  ;  but  when  it  is  near 
the    cervix,    it    may  easily   be  mistaken   for   a    polypus   not  yet 
expelled,  especially  if  there  be  hemorrhage  ;  because,  if  a  polypus 
be  inclosed  in   the   body  of  the  uterus,    all   the  signs  of  fibrous 
tumor  will  be  present,  with  hemorrhages,  but  no  special  indication 
of  polypus.     In   process  of   time,  however,  the  polypus  will  be 
forced  through  the   os  uteri,   and   its  progress  indicated  by  the 
descent  of  the  tumor,  and  the  gradual  obliteration  of  the  cervix 
uteri.     It   should,  also,  be  remembered   that  a  fibrous  tumor,  at 
this  part    especially,  is   convertible   (by  a  gradual  progress)  into 
a  polypus.     If  the  finger  can  be  introduced  through  the  os  uteri, 
\ve  may,  perhaps,  be  able  to  discover  the  character  of  the  tumor  ; 
and  the  absence  of  expulsive  efforts  after  the  disease  has  lasted 
some  time,  will  be  additional  evidence  in  favor  of  its  being  the 
disease  under  consideration  ;  but  it  must  be  confessed  that  the 
diagnosis  is  not  always  an  easy  one. 

625.  Treatment. — We  have  here  a  disease  that  admits  of  but 
very  little  treatment.     So  long  as  it  does  not  interfere  with  the 
patient's  health,  no  treatment  is  necessary;  should  it,  however, 
create  any  disturbance  of  the  general  health,  or  of  the  functions 
of  neighboring  organs,  these  will  have   to  be  treated  on  general 
principles. 

626.  This  does  not  seem  like  a  very  satifactory  treatment  for 
such  a  common  disease,  but  can  we  do  more  ?     Dr.  Simpson  states 


304  DISEASES     OF     WOMEN. 

that,  under  the  use  of  the  Bromide  of  Potassium,  he  has  seen 
these  tumors  decrease  much  in  size.  In  one  patient  the  uterine 
fibroid  tumor  was  of  large  size,  and  incommoded  the  patient 
much  from  its  weight  and  pressure.  Under  the  use  of  the  Bro- 
mide of  Potassium  and  local  leeching,  continued  in  perseveringly 
for  many  long  months,  the  tumor  involved  and  decreased  in  a 
most  marked  manner,  and  her  health  and  power  of  walking  and 
exertion  became  quite  restored.  He  says,  "  I  have  found  the 
same  remedy  succeed  in  several  similar  cases,  in  arresting,  and, 
more  or  less,  reducing  uterine  fibroids,  and  again,  in  others,  I 
have  seen  it  fail.  But  to  most  persons,  the  Bromide  of  Potassium 
can  be  given  for  a  great  length  of  time  without  any  interference 
with  the  general  health.  In  fact,  it  usually  serves  apparently  as  a 
tonic  as  well  as  a  deobstruent,  in  this  respect  having  a  marked 
advantage  over  Iodide  of  Potassium."  Dr.  Ashwell  thinks  that  the 
use  of  Iodine  has  been  attended  with  benefit  in  his  practice.  He 
administers  the  Iodine  internally,  and  uses  an  ointment  com 
posed  of 

R    Iodine,  gr.  v. 

Iodide  of  Potassium,  3i. 

Adeps  Preparata,  3j. 

M.  Ft.  Unguentum.     This  is  applied  to  the  cervix  uteri. 

627.  He  draws  the  following  inferences  from  the  use  of  this 
medicine  : — First,    its    internal    administration,    and    its   use    by 
inunction,  are  decidedly  beneficial ;  the  advantage,  if  the  remedy 
be  judiciously  employed,  being  rarely  attended  with  constitutional 
injury.     Secondly,  in  hard  tumors  of  the  walls  or  cavity  of  the 
uterus,  resolution  or  disappearance  is   scarcely  to  be   expected, 
since  the  growths  are  adventitious  or  parasite,  and  not  imbedded 
in  glandular  structure.     Hence,  the  prevention  of  further  deposit, 
in   other  words,   the  restraint  of   the  lesion  within  its   present 
limits,  and  the   improvement  of  the  general  health,  will  be  the 
extent  of  the  benefit  derived. 

628.  Prof.  Howe  has  employed  injections  into  the  structure  of 
uterine  fibroids  with  great  success.     He  uses  a  large  hypodermic 
syringe  made  for  the  purpose,  and  injects  from  one  to  two  drachms 


FIBROID     TUMORS.  305 

of  tincture  of  Iodine,  repeating  it  every  week.  The  object  is  to 
reach  and  destroy  the  center  of  growth,  and  experience  proves 
that  this  can  be  done  with  safety. 

629.  If  the  tumor  lies  next  to  the  mucous  membrane  of  the 
uterus,  and  especially  if  it  projects  into  its  cavity,  and  hemorr- 
hage,   or  any  other    dangerous   symptom  should   present,   it  has 
been   recommended  by  Lisfranc   and  other  French  authorities,  to 
enucleate  and  remove  the  tumor.     This  they  propose  to  accom- 
plish by  dividing  the  mucous  membrane  over  the  tumor  with  a 
scalpel  or  the  finger-nail,  and  then  separating  it  from  the  uterus 
by  the   finger.     Dr.   Simpson   reports  a   case  of  a  large  fibrous 
tumor,   weighing    three    pounds,  eight    ounces,   imbedded   in    the 
posterior  Avail  of  the  uterus,  and  protruding  downward  upon  the 
top   of  the  vagina.     He  made  an  opening,  by  means  of  caustic- 
potash,  into  the  most  prominent  part  of  the  tumor;    through  this 
opening    he    could    pass    his    finger    entirely  around    the    tumor, 
between  it  and  its  uterine  envelop.     On  the  second  day  after  the 
caustic    was    applied,    the    artificial    opening   was    considerably 
dilated ;  on   the  fifth,  a  portion  of  the  tumor  was   expelled  under 
the  influence  of  ergot.     On  the  twelfth  day,  while  she  was  under 
the  influence  of  chloroform,  he  passed  his  hand  up  by  the  side  of 
the  tumor,  completed  the  separation  of  the  remaining  adhesion, 
like  an  adherent  placenta,  and  brought  away  the  tumor  in  one 
mass. 

630.  In  those  cases  in  which  the  tumor  has  separated  itself 
from  the  uterine  wall,  being  merely  attached  by  a  pedicle  formed 
of  the  uterine  mucous  membrane,  the  treatment  will  be  the  same 
as  for  fibrous  polypi. 

631.  Symptoms  of  Pediculated  Fibroid   Tumors — Polypi. — In 
an  early  stage  of  the  growth  of  these  tumors,  the  symptoms  are 
very  obscure,  but  when  more  advanced  they  assume  a  formidable 
and  dangerous  character.     In  many  instances,  the  first  symptoms 
that  will  be  noticed  are  similar  to  those  of  the  fibrous  tumor,  such 
as  a  feeling  of  weight  in  the  pelvis,  bearing  down,  pain   in  the 
loins,  etc.,  which  are  especially  aggravated  during  the  menstrual 
periods.     The    menstrual    function    is    usually    first    affected ;    it 
becomes  more  profuse    and   protracted,  and  occurs   at  irregular 

20 


506 


DISEASES     OF     WOMEN 


intervals.  At  the  commencement  of  the  growth  there  is  usually 
more  or  less  leucorrhea ;  sometimes  the  discharge  is  principally 
the  normal  mucus  of  the  parts,  at  others  it  is  fetid  and  bloody. 
These  symptoms  may  continue  for  a  longer  or  shorter  time,  owing 
to  the  growth  of  the  polypus,  and  constitutional  peculiarities  of 
the  patient. 


FIG.  28. — PEDTCULATED  POLYPUS  ARISING  FROM  THE  FUXDUS  OP  THE  UTERUS 

bb,  Section  of  the  Cervix  Uteri,  to  show  the  form  and  attachment  of  the  Polypus; 
dd,  The  club-shaped  Extremity  of  the  Tumor. 

632.  As  the  growth  advances  in  size,  and  in  many  cases  where 
it  is  still  very  small,  the  hemorrhages  become  more  frequent,  and 
increased  in  quantity.  This  loss  of  blood  is  sometimes  so  profuse, 
as  to  give  the  patient  a  blanched  and  bloodless  appearance,  and 
to  greatly  impair  the  general  health.  The  appetite  becomes 
impaired,  the  bowels  relaxed,  osdema  of  the  extremities  occurs, 
etc.,  marking  an  extreme  state  of  debility  from  loss  of  blood. 
Another  prominent  symptom  in  polypus  of  the  uterus  is  nausea 


F 1 B  R 0  ID     T U M 0 R  S . 


307 


and  frequent  vomiting  ;  this  is  probably  caused,  in  part,  by  the 
loss  of  blood,  and  partly  by  the  dragging  down  of  the  polypus 
and  the  expulsive  efforts  of  the  uterus. 

633.  These  symptoms  are  arranged  in  the  following  order  by 
Boivin  and  Duges:  1.  Sympathetic  affections,  the  least  indicative 
of  all,  as  efforts  at  vomiting,  paleness,  and  anas-area.  2.  Leucorr- 
hea,  sometimes  preceding  the  formation  of  the  polypus,  sometimes 
occurring  a  long  while  afterward,  and  existing  alone,  chieflv  when 


FIG.  29. — LONG  PEDICTTLATED  POLYPUS  OF  THE  UTERUS,  PROTRUDED  THROUGH  THB 

Os  EXTERNUM. 


308  DISEASES    OF    WOMEN. 

the  tumor  arises  from  the  cervix  uteri.  3.  Frequent,  abundant, 
and  prolonged  menorrhagia.  4.  Profuse  hemorrhage  (especially 
when  the  polypus  occupies  the  body  of  the  uterus),  occasioning 
debility,  exhaustion,  and  death.  5.  Sense  of  weight  in  the 
hypogastrium,  and  afterwards  upon  the  rectum,  a  feeling  of 
distension  within  the  pelvis,  draggings  in  the  loins  and  groins, 
and  sometimes  retention  of  the  faeces  and  urine.  The  coincidence 
of  the  last  symptoms  implies  considerable  volume  in  •  the  tumor, 
Avhich  also  facilitates  the  discovery  by  examination.  But,  so  long 
as  the  polypus  is  concealed  within  the  uterus,  all  that  can  be 
ascertained  is  the  increased  size  of  that  organ.  If  the  polypus  be 
situated  at  the  os  uteri,  or  at  the  cervix,  already  begun  to  be 
dilated,  or  later  in  the  disease,  if  suspended  from  the  fundus,  it 
may  be  ascertained  by  an  examination  per  vaginam.  As  soon  as 
the  cervix  of  the  uterus  has  begun  to  expand,  the  os  uteri  partly 
opens,  and  the  finger  being  introduced,  the  convex  surface  of  the 
tumor  is  felt,  and  the  nature  and  cause  of  the  affection  become 
probable.  Before  the  tumor  has  protruded  from  the  os  uteri,  this 
mode  of  examination  may  be  assisted  by  pressure  upon  the 
hypogastrium — the  uterus,  already  low,  by  reason  of  the  weight 
of  the  polypus  and  the  relaxation  of  its  own  ligaments,  being 
further  depressed  by  that  pressure.  The  diagnosis  is  sometimes 
more  easily  determined  at  this  stage  of  the  disease  than  at  a 
later  period;  the  point  of  the  insertion  of  the  tumor,  and  the 
state  of  the  uterus  can  then  be  better  ascertained,  than  when 
the  polypus  has  advanced  through  the  os  uteri,  occupies  the 
vagina,  or  pelvic  cavity,  or  even  protrudes  beyond  the  os 
externum. 

634.  The  presence  of  a  small  polypus  does  not  prevent  con- 
ception, and  even  utero-gestation  may  go  on  to  the  full  period. 
This,  however,  is  not  common,  the  irregularity  of  the  menstrul 
function  caused  by  the  tumor  generally  proving  a  cause  of  sterility, 
and  even  should  conception  occur,  an  abortion  will  most  frequently 
take  place  during  some  period  of  gestation. 

635.  The  presence  of  a  polypus  sometimes  proves  a  cause  of 
difficult  labor,  the  tumor  being  extruded  before  the  child  and  still 
attached  to  the  uterus,  prevents  its  passage,  and  the  tumor  may 


FIBROID     TUMORS.  309 

require  to  be  removed  before  the  child  can  be  born.  It  may  like- 
wise be  the  cause  of  subsequent  danger,  by  preventing  the  con- 
traction of  the  uterus,  necessary  to  close  the  open  mouths  of  the 
uterine  vessels,  and  by  this  means  give  rise  to  dangerous,  if  not 
fatal  flooding.  Metritis  has  also  been  known  to  result,  where  a 
polypus  was  retained  in  the  cavity  of  the  uterus  after  delivery. 

636.  Dr.  Montgomery  of  Dublin,  has  given  this  subject  a  care- 
ful investigation,  and  the  following  conclusions,  the  results  of  his 
experience,  will  be  found  to  give  a  full  and  correct  view  of  the 
entile  subject.  "1.  That  small  polypi,  or  polypoid  excrescences, 
are  of  frequent  occurrence.  2.  That  they  are  often  not  discern- 
ible by  the  touch  alone,  and  so  escape  notice.  3.  That  they  may 
even  elude  detection  with  the  speculum,  unless  the  instrument  is 
capable  of  separating  the  lips  of  the  os.  4.  That  they  are  a 
common  cause  of  ulceration  and  menorrhagia,  the  cure  of  which 
requires,  as  a  preliminary,  the  removal  of  the  polypi.  5.  That 
while  thus,  on  the  one  hand,  a  small  polypus  may  escape  detection, 
there  is,  on  the  other  hand,  a  peculiar  condition  of  the  anterior  lip 
of  the  os  uteri,  liable  to  be  mistaken  for  a  polypus,  and  requiring 
a  long  time  for  its  removal.  6.  That  the  very  small  polypus  of 
the  os  uteri  is  seldom  solitary,  and  in  common  with  polypi  of  other 
kinds,  is  very  often  combined  with  other  diseases  of  the  uterus, 
especially  with  fibrous  tumors.  7.  That  these  small  polypi  of  the 
os  uteri,  when  occurring  in  women  of  advanced  age,  especially  if 
they  are  of  the  vesicular  kind,  are  often  the  precursors  of  a  malig- 
nant form  of  diseases.  8.  That  from  polypus,  being  very  fre- 
quently accompanied  by  ulceration  of  the  os  and  cervix  uteri,  and 
from  its  concomitant  pain  and  structural  alteration,  the  symptoms 
are  occasionally  mistaken  for  those  of  cancer,  which  error  is  most 
likely  to  be  committed,  if  an  examination  should  happen  to  be 
made,  just  when  a  polypus  of  large  size  is  passing  through,  but 
still  engaged  in,  and  distending  the  os  uteri.  9.  That  in  cases  of 
larger  sized  polypi,  ligature  is  the  means  most  eligible,  as  being 
safer  than  excision,  though  not  so  expeditious ;  its  application 
having  in  general  the  immediate  effect  of  restraining  the  morbid 
discharges,  and  ultimately  curing  the  disease.  10.  That  polypi 
and  polypoid  growths,  of  small  size,  are  best  removed  by  torsion, 


oil)  DISEASES     OF     WOMEN. 

or  in  some  circumstances  their  destruction  may  be  conveniently 
accomplished  with  caustic.  11.  That  with  large  polypi,  torsion  is 
unsafe,  and  should  not  be  attempted.  12.  That  even  with  one  of 
small  size  and  slender  pedicle,  excision  is  not  free  from  risk  of 
troublesome  hemorrhage.  13.  That  in  ordinary  cases  of  benign 
polypus,  when  no  uterine  disease  exists,  the  removal  of  the  tumor 
by  ligature  is,  in  a  vast  majority  of  instances,  completely  success- 
ful, even  in  apparently  hopeless  cases.  14.  That  in  malignant 
growths,  such  as  cauliflower  excrescence,  removal  by  ligature  Avill 
sometimes  effect  a  complete  cure ;  and  that  when  success  is  not  so 
decided,  much  good  may  be  done  by  the  operation.  15.  That  the 
situation  whence  a  polypus  springs,  makes  a  great  difference  in  the 
symptoms  which  it  induces  ;  a  polypus  of  the  lip  of  the  os  gives 
rise  to  fewer  symptoms  and  less  discharge,  than  one  of  smaller 
size  springing  from  within  the  os  uteri.  16.  That  fibrous  tumors 
formed  in  the  substance  of  the  uterus,  may  thence  descend,  pass 
through  the  os,  and  form  an  ordinary  pediculated  polypus  in  the 
vagina.  17.  That  in  the  unimpregnated  uterus,  this  change  will 
be  effected  gradually  and  slowly,  but  that  should  pregnancy  occur, 
expulsion  of  the  tumor  may  take  place  rapidly,  under  the  action 
of  labor.  18.  That  a  polypus  of  large  size  may  make  its  first 
appearance  immediately  after  delivery.  Lastly.  That  the  cure  of 
long  standing  polypus,  with  copious  discharge,  is  liable  to  be 
followed  by  a  condition  of  system,  requiring  to  be  followed  by 
precautions  against  a  determination  to  the  head. 

637.  Diagnosis. — We  have  to  distinguish  polypus  of  the  uterus 
from  pregnancy,  vaginal  hernia,  vaginal  prolapse,  cystocele  and 
rectocele,  scirrhus   or   cancer   uteri,  caulifloiver   excrescence,  pro- 
lapsus uteri,  inversion  of  the  womb,  and  from  chronic  enlargement, 
or  induration  of  the  uterus. 

638.  It  may  be  distinguished  from  pregnancy  by  the  absence 
of  the  audible  and  tangible  signs,  by  the  gradual  progress  of  the 
disease,  and  by  the  frequent  recurrence  of  hemorrhage. 

639.  From  vaginal  hernia,  by  the  elastic  feel  of  the  intestinal 
protrusion,  by  its  perfect  sensibility  to  the  touch,  by  its  being 
covered  by  the  mucous  membrane  of  the  vagina,  while  in  polypus 
the  finger  can  be  passed  entirely  around  the  tumor  up  to  the  os 


FJI1KOII)     TUMORS.  311 

uteri,  and  by  its  being  generally  reducible  on  compression,  and  by 
its  giving  the  characteristic  succussion  when  the  patient  coughs. 

040.  It  may  be  distinguished  from  vaginal  prolapse  of  the 
entire  circumference  of  the  vagina,  by  the  central  opening  in  the 
tumor  in  this  disease,  through  which  the  finger  may  be  passed  up, 
so  as  to  detect  the  os  uteri  in  situ.  From  vaginal  cystocele  and 
rectocele,  by  the  fact,  that  they  are  covered  by  the  vaginal  mucous 
membrane,  and  that  the  finger  may  be  passed  up  to  the  os  uteri, 
either  anterior  or  posterior  to  them,  the  os  being  found  free  from 
the  disease. 

641.  From  cancer  of  the  uterus,  by  the  severe  pain  and  other 
symptoms  which  generally  attend  malignant  disease,  and  by  the 
results  of  a  vaginal  examination ;  for  if  the  polypus  can  be  felt, 
it  will  not  be  sensible  on  pressure,  and  if  its  pedicle  can  be  dis- 
tinguished, the  evidence  will  be  positive.     Again,  cancer  of  the 
uterus,  in  nearly  every  instance,  commences  in   the  cervix,  while 
the  contrary  is  the  case  with  polypi. 

642.  From   cauliflower   excrescence,   by   its    greater    hardness 
and  smoothness,  by  its  not   bleeding  when   touched,  and  by  the 
situation,  of  the  tumor. 

643.  From  prolapsus  uteri,  by  the  os  uteri  in  this  case  being 
found  at  the  lower  part  of  the  tumor,  through  which  the   sound 
may  be  introduced  into  the  uterine  cavity.     The  hemorrhages  are 
also  absent  in  prolapsus,  and  the  protrusion  is  equally  sensitive 
throughout,  while  the  polypus  is  insensible. 

644.  From  inversion  of  the  uterus,  by  the  gradual  appearance 
of  the  tumor;   while   inversion   generally   occurs    suddenly   after 
labor,  and  is  accompanied  with  collapse,  hemorrhage,  etc.     When 
inversion  is  gradual,    it  is   always   effected   by   the   weight   of  a 
fibrous  tumor  or  polypus,  and  in  this  case,  the  tumor  would  be 
found  depending   from  its  fundus.     The  surface  of    an  inverted 
uterus  is  rough,  while  that  of  a  polypus  is  smooth,  and  the  sensi- 
bility is  greater  and  more  universal  in  inversion  than  in  polypus. 

645.  From  chronic  enlargement  and  induration  of  the  uterus, 
by   the  diffused  swelling  and   tenderness  on  pressure,  when   the 
womb  is  thus  diseased,  while  polypi  are  well  defined,  and  nearly 
insensible. 


312  DISEASES     OF    TFOMEN. 

646.  Prognosis. — So  long  as  the  polypus  continues  attached  to 
the   uterus,  there  is   always   danger,   especially  is   this  the  case 
when  it  is  shut  up  in  its  cavity,  and  inaccessible  to  the  hand  of 
the  surgeon.     Sudden  and  profuse  hemorrhage,  or  less  but  more 
frequent  losses  of  blood,  may  exhaust  and"  debilitate  the  patient, 
thus  rendering  her  liable  to  be  taken  off  by  any  disease,  or  they 
may  of  themselves  prove  suddenly  fatal.     If,  however,  the  disease 
be  ascertained,  the  prognosis  should  be  favorable,  providing  the 
constitution   is   not  seriously   injured,   for    after   the    polypus    is 
removed,  the  patient  generally  recovers  her  health  rapidly. 

647.  Treatment. — With  the  exception  of  a  proper  attention  to 
the   general  health,   which   is   necessary  in    all    uterine   diseases 
where  the  constitution  is  liable  to  suffer,  the  treatment  is  entirely 
surgical.     The  first  indication    is    always  to    remove   the  tumor 
when  it  is  so  situated  that  this  can  be  done.     Four  means  of  their 
removal  are  presented  to  us  :  1.  By  ligature,  strangulating  the 
tumor,  and  allowing  it  to  slough   off.     2.  By  torsion,  seizing  the 
tumor  with  a  proper  instrument,  and  twisting  it  off.     3.  By  excis- 
ion, some  authors  recommend  the  application  of  the  ligature,  and 
the  excision  of  the  tumor  beyond  it.     4.  By  the  use  of  caustic, 
disorganizing  its  pedicle. 

648.  Ligation. — This  method  of  removing  polypi  is  considered 
by  most  authors  as  preferable  to  any  other,  not  only  from  the 
safety  of  the  operation,  but  little,  if  any  hemorrhage  occurring 
after  its  application,  but  also  from  the  general  success  attending 
its  use.     The  objections  urged  against  it,  are  :  the  difficulty  of  its 
application  in  many  cases,  the  length  of  time  that  it  takes  to 
separate  the  tumor,  the  severe  irritation  that  follows  its  use,  and 
the  putrid  and  offensive  discharge  which  sometimes  arises  from  the 
disorganization  of  the  mass,  which  causes  irritation  of  the  genital 
organs,  or  may  be  absorbed,  producing  severe  or  fatal  irritative 
fever. 

649.  The  ligature  may  be  employed   for   the   removal  of   a 
polypus  in  any  situation,  providing  its  pedicle  can  be  traced  from 
the  body  of  the  tumor  toward  its  insertion  for  a  sufficient  distance 
to  admit  of  the  application  of  the  ligature  to  it.    Where  no  serious 
symptoms  arise  from  its  presence,  no  operative  interference  is 


FIBROID     TUMORS.  313 

justifiable,  until  the  polypus  has  passed  through  the  os  uteri  into 
the  vagina.  If  the  os  uteri  is  rigid,  not  dilating  readily,  espe- 
cially if  the  polypus  is  large,  as  may  be  known  by  the  size  of  the 
uterus,  it  has  been  recommended  to  use  the  lobelia,  to  assist  in  the 
dilatation.  It  has  also  been  recommended  to  use  the  ergot,  to 
hasten  the  expulsion  of  the  tumor,  especially  if  the  polypus  at 
times  appears,  and  then  disappears.  The  propriety  of  these 
measures  depend  upon  the  symptoms  present;  thus,  if  there  be 
profuse  flooding,  or  if  the  hemorrhage  is  of  very  frequent  recur- 
rence, debilitating  the  patient,  and  endangering  her  life,  these 
means  may  be  employed,  or  the  ligature  applied  while  the  tumor 
is  Avithin  the  uterus,  as  will  be  hereafter  described;  but  if  there 
be  no  dangerous  symptoms,  we  should  wait  until  the  polypus  was 
naturally  extruded. 

650.  Many  modes  of  applying  the  ligature  have  been  recom- 
mended, and  instruments  innumerable  invented  for  the  purpose, 
but  all  that  we  desire  for  practical  purposes,  is  a  knowledge  of 
one  instrument,  and  the  mode  of  its  application  ;  if  this  one  be 
adapted  to  meet  the  indications  of  every  case  that  presents. 
•Such  an  instrument  we  have,  in  the  double  cannula  of  Dr.  Gooch, 
(see  plate  80,)  and  as  it  has  been  variously  modified  by  different 
practitioners.  Dr.  Gooch  gives  the  following  description  of  the 
instrument,  and  his  mode  of  using  it :  "  The  instrument  which  I 
use  for  this  purpose,  and  which,  in  numerous  cases,  has  assisted 
me  through  the  operation,  consists  of  two  silver  tubes,  each  eight 
inches  long,  perfectly  straight,  separate  from  one  another,  and 
open  at  both  ends.  A  long  ligature,  consisting  of  strong  whip- 
cord, is  to  be  passed  up  the  one  tube  and  down  the  other,  and  the 
two  ends  of  the  ligature  hang  out  at  the  lower  ends ;  the  tubes 
are  now  to  be  placed  side  by  side,  and  guided  by  the  finger,  are 
to  be  passed  up  the  vagina,  along  the  polypus,  till  their  upper 
ends  reach  that  part  of  the  stalk  round  which  the  ligature  is  to  be 
applied ;  and  now  the  tubes  are  to  be  separated,  and  while  one  is 
fixed,  the  other  is  to  be  passed  quite  around  the  polypus,  till  it 
arrives  again  at  its  fellow-tube,  and  touches  it.  It  is  obvious  that 
a  loop  of  the  ligature  will  thus  encircle  the  stalk.  The  two  tubes 
•are  now  to  be  joined,  so  as  to  make  them  form  one  instrument; 


311 


DISEASES      OF      WOMEN. 


for  this  purpose,  two  rings  joined  by  their  edges,  and  just  large 
enough  to  slip  over  the  tubes,  are  to  be  passed  up  till  they  reach 
the  upper  ends  of  the  tubes  immovably.  Two  similar  rings,  con- 
nected with  the  upper  by  a  long  rod,  are  slipped  over  the  lower 
ends  of  the  tubes,  so  as  to  bind  them  in  like  manner ;  thus,  the 
tubes,  which  at  the  beginning  of  the  operation  we're  separate,  are 
now  fixed  together  as  one  instrument.  By  drawing  the  ends  of 
the  ligatures  out  at  the  lower  external  ends  of  the  tubes,  and 
then  twisting  and  tying  them  on  a  part  of  the  instrument  which 
projects  from  the  lower  rings,  the  loop  around  the  stalk  is  thereby 
tightened,  and,  like  a  silk  thread  round  a  wart,  it  causes  it  to  die 
and  fall  off." 


FIG.  30.— DOUBLE  CANNULA. 


651.  After  the  ligature  has  been  applied,  the  patient  must  be 
cautioned  against  any  sudden  movements,  as  serious  injury  might 
occur,  if  the  cannula  was  forced  upward;  to  diminish  the  liability 


FIBROID     TUMORS.  oli) 

of  this  danger,  it  is  recommended  that  the  cannula  be  applied  and 
left  anterior  to  the  polypus.  The  frequency  with  which  the  liga- 
ture will  have  to  be  tightened  will  vary  according  to  the  degree 
of  irritation  produced  by  it.  Thus,  if  there  be  but  slight  irrita- 
tion, the  ligature  may  be  tightened  every  twenty-four  hours,  until 
the  polypus  is  detached.  Sometimes,  however,  the  irritation  and 
pain  is  so  great  that  the  ligature  will  have  to  be  loosened  after 
its  first  application,  until  this  has  subsided  ;  at  other  times, 
tightening  the  ligature  every  two  or  three  days  will  be  often 
enough.  The  vagina  should  be  syringed  out  once  or  twice  a  day 
with  warm  water,  or  warm  water  and  castile  soap,  to  remove  any 
offensive  discharge,  and  it  will  also  render  the  patient  much  more 
comfortable.  In  from  six  days  to  three  weeks  the  cannula  will 
come  away,  and,  if  the  polypus  be  small  it  will  pass  with  it ;  but, 
if  large,  it  may  have  to  be  removed  with  the  hand,  or  with 
hooked  forceps.  The  discharge,  after  the  polypus  is  removed, 
will  often  be  very  profuse,  sometimes  fetid,  and  injections  of  warm 
wrater  should  be  frequently  used  to  remove  it;  if  it  be  fetid,  a 
weak  solution  of  chlorinated  soda  should  be  used  for  the  injection. 
In  the  majority  of  cases,  not  a  drop  of  blood  is  discharged  from 
the  time  the  ligature  is  applied,  and  the  portion  of  the  pedicle 
attached  to  the  uterus  is  gradually  disorganized  and  discharged. 

652.  If  a  polypus  be  retained  within  the  cavity  of  the  uterus, 
and  gives  rise  to  such  profuse  hemorrhage  as  to  endanger  the  life 
of   the   patient,   it   will   be   necessary  to  dilate  the  os  uteri  and 
apply  the   ligature   within   the   uterus.     This    dilatation  may  be 
readily  effected  by  the  use  of  the  sponge-tents  heretofore  described. 
The  first  tent  that  is  used  wrill,  if  well  made,  expand  in  from 
twenty  to  thirty  hours,  and  open  the  os  to  such  an  extent  that  the 
finger  may  be  introduced  ;  it  should  be  followed  by  larger  ones, 
until  sufficient  dilatation  is  effected.     There  is  a  probability  that 
when  the  cervix  is  dilated  in  this  manner,  the  polypus  will  descend 
into  the  vagina  ;  if  it  does  not,  the  ligature  may  be  applied  in 
the  cavity  of  the  uterus  in  the  same  manner  as  described  above. 

653.  Another  instrument  for  removing  these  polypi,  that  might 
be  used  with  much  advantage,  is  the  Ecraseur  of  Chassaignac. 
The    principle    upon   which    this  instrument   acts,   is  by  a   slow 


316 


DISEASES      OF      W 0 M  E  X , 


division  of  the  tissues,  not  cutting,  but  crushing  them  off;  there  is 
no  hemorrhage  following  its  use,  no  danger  of  phlebitis  or  of 
irritative  fever  ;  it  removes  the  tumor  in 
a  very  short  time,  and  thus  supersedes 
the  use  of  the  knife.  The  ecraseur  con- 
sists of  a  handle  and  steel  cannula,  within 
which  are  grooves  for  the  passage  of  a 
jointed  chain,  like  a  chain-saw,  but  with- 
out any  teeth,  or,  perhaps,  more  like  the 
chain  used  in  watches,  the  edge  beincr 

'  O  O 

blunted,  but  not  serrated.  From  the 
extremity  of  the  cannula  projects  a  loop, 
as  long  as  may  be  required,  which  is 
passed  around  the  tumor,  and  gradually 
tightened,  the  handle  being  moved  once 
in  fifteen  seconds,  when  a  little  click  is 
heard,  and  the  chain  tightened,  by  the 
drawing  into  the  groove  of  one  of  the 


FIG.  31. — THE  ECRASEUR. 


DESCRIPTOR. — The  Ecraseur  described  above  is  tho 
instrument  made  use  of  by  English  and  French  Sur- 
geons. It  is  a  somewhat  complicated  and  expensive 
instrument,  but  it  can  be  much  simplified.  Fig.  31 
represents  the  simplest  form  of  the  instrument ;  it  con- 
sists of  an  iron  or  steel  cannula,  a,  ten  inches  long  and 
half  an  inch  in  diameter  ;  this  is  terminated  internally 
by  an  arm,  e,  to  which  the  fixed  extremity  of  the  chain 
is  attached.  The  chain,  f,  is  from  six  to  eight  inches 
in  length,  attached  by  one  extremity  to  the  arm  of  the 
cannula,  the  other  passing  into  the  cannula  at  d,  is  con- 
nected with  the  screw,  b.  The  cavity  of  the  cannula  is 
circular,  and  of  sufficient  size  to  admit  the  screw,  but 
having  a  groove  on  each  side  to  receive  a  square  block 
half  an  inch  in  length,  which  terminates  the  chain,  and 
through  which  the  screw  passes,  terminating  in  a  button 
beyond.  The  screw  is  of  the  same  length  as  the  in- 
strument, and  works  in  a  nut  cut  in  the  raised  portion 
seen  at  the  outer  extremity  of  the  cannula,  and  which 
is  attached  to  it  by  means  of  a  screw.  In  drawing  the 
links  of  the  chain  into  the  cannula,  the  screw  acts  upon 
the  plate  terminating  the  chain,  which  being  received 
into  the  grooves  of  the  cannula,  is  prevented  from  turn- 
ing, thus  keeping  the  chain  straight.  The  two  whale- 
bone staffs,  gy,  are  intended  to  assist  the  surgeon  in 
carrying  the  chain  up  to  the  pedicle  of  the  polypus. 


FIBROID     TUMORS.  317 

links.  This  process  continues  till  all  the  links  are  drawn  into 
the  cannula,  and  the  tumor  is  cut  off'.  This  slow  method  of  pro- 
ducing strangulation  and  division  of  the  growth,  entirely  prevents 
any  hemorrhage.  A  contused  wound  is  produced,  and  the  orifices 
of  the  vessels  are  thus  closed.  With  this  instrument  a  polypus 
might  be  removed  in  from  five  to  thirty  minutes. 

654.  This  instrument  is  much  used  by  the  Paris  surgeons  for 
the  removal  of  vascular  tumors,  cancerous  growths,  hemorrhoids, 
in    fact,    prominent    tumors    of   almost   every  kind.     I   have   no 
account  of  its  use  in  removing  polypi,  but  the  adaptation  of  the 
instrument  for  this  purpose  can  be  seen  at  a  glance.     The  follow- 
ing cases  will  serve  to   illustrate  its   use,   in  each  of  these   the 
patient   was   under    the   influence    of   chloroform  ;    Mr.  Erichsen 
removed  some  piles,  partly  internal  and  partly  external,  with  this 
instrument,  the  chain  was  applied  round  the  tumor,  arid  in  the 
course  of  five  minutes  and  a  quarter  the  mass  was  completely  cut 
off  without  being   followed    by  the   slightest   bleeding   whatever. 
Mr.    Stanley    removed    a    warty    exudation     from     an    epithelial 
chimney-sweeper's  cancer  of  the  scrotum,  with  the  same  result. 
Mr.   Lawrence  removed  a  very  large    cellular    tumor,  weighing 
nearly  a  pound  and  a  half,  and  in  size  equal  to  a  small  child's 
head,  from  one  side  of  the  generative  organs  of  a  young  woman 
aged  thirty.     Seven  minutes  sufficed  to  completely  detach  it ;  it 
was  followed  by  no  bleeding,  no  ligatures,   and  the  parts  were 
brought   together   by   sutures.      Mr.  Paget   removed  a  vascular 
growth  in  connection  with  the  clitoris  and  labium,  so  commonly 
met  with  in  females,  it  was  attended  with  the  same  success  and 
the  same  result  as  in  the  other  two. 

655.  From  these  cases,  and  others  which  have  been  reported, 
I  should  much  prefer  this  mode  of  removing  these  growths  to  any 
other.     Its  advantages  over  other  modes  are,  first,  the  quickness 
of  the  operation,   the   tumor  being   removed  in    a   few  minutes, 
instead  of  from  eight  to  twenty-one  days  as  is  the  case  with  the 
ligature.     Second,  its  safety,  no  hemorrhage  or  other  bad  result 
following  its  application. 

656.  It  might  be  urged  against  the  use  of  this  instrument,  that 
its  application  would  be  difficult,  but  if  the  following  directions  be 


318  DISEASES     OF    WOMEX. 

observed, it  maybe  applied  as  readily  as  the  ligature.  In  addition 
to  the  instrument  described,  two  conducting  rods  should  be  made 
of  whalebone,  each  nine  or  ten  inches  in  length,  and  having  a 
groove  or  mortise  at  one  extremity  sufficiently  large  to  receive 
the  chain.  (Fig.  31  gg.)  The  loop  of  the  ecraseur  being  then 
made  sufficiently  long  to  pass  over  the  polypus,  it  may  be  carried 
up  with  the  conducting  rods  an*1  \he  cannula.  We  thus  have 
the  chain  supported  at  three  points,  and  by  this  means  it  can  be 
accurately  applied. 

657.  Torsion. — Small  polypi  or  polypoid  growths  from  the  os 
or  cavity  of  the  cervix  may  be  easily  removed,  by  seizing  them 
with  a   pair  of  polypus-forceps,   and    twisting   them   off.     Or,  in 
many  cases,  the  polypus  might  be  seized  with  the  fingers,  and 
twisted  off,  especially   if  the  pedicle  be  small.     Xo  hemorrhage 
ever  follows  their  removal,  by  this  method,  when  it  is  appliable, 
and  all  that  need  be  done  afterward,     beside     attending  to  the 
general  health,    is   to   keep   the   vagina   cleansed  by  the  use  of 
injections. 

658.  Excision. — This  mode  of  removing  polypi  is  preferred  by 
many   authors,   among   the  most  prominent   of  whom   might   be 
mentioned   Dieflfenbach,    Dupuytren,    Siebold,    Arnalt,    Simpson, 
and  Brown.     Dupuytren  removed  200  polypi  in  the   course   of 
his  practice  in  this  manner,  and  hemorrhage  occurred  but  twice 
in  so  large  a  number.     According  to  Siebold  the  following  cir- 
cumstances should  cause  us  to  prefer  excision  to  the  ligature  :  — 
"1.    When  the  polypus  is  either  detruded  from  the  uterus,  or  can 
be  drawn  down  with  a  pair  of  forceps,  or  when  it  is  attached  to 
the  os  or  cervix  uteri,  the  stalk  being  thin,  and  there  being  little 
evidence  of  vascularity.     2.    When  the  ligature  has  been  applied 
for  some  time,  and  the  polypus  is  within  reach,  it  may  be  excised 
below  the  ligature.     3.    When  the  stalk  of  the  polypus  does  not 
separate    after    the    application    of  the    ligature.     4.    When  the 
polypus  has  entailed  an  inversion  of  the  uterus.     And   that  the 
two  following  circumstances  are  the  only  cases  in  which  the  liga- 
ture is  preferable  :  —  1.    When  an  artery  can  be  felt,  pulsating  in 
the  neck  of  the  polypus.     2.   When  the  tumor  is  so  thick  that  it 


FIBROID    TUMORS.  Ol9 

probably  contains  large  vessels."     Mr.  Baker  Brown  first  ligates 
the  polypus,  and  then  divides  its  pedicle  below  the  ligature. 

659.  The  objections    urged    against    excision    are — First,  the 
danger  of  hemorrhage  ;  but  this,  according  to  the  authors  above- 
quoted,  is   very   uncommon,  and   when   it   does    occur,  it  may  be 
readily  arrested  by  the  tampon  :   Second,  that  more  or  less  injury 
is  always  liable  to  occur  to  the  pelvic  attachments  of  the  uterus, 
if  it  and  the  polypus  arc  forcibly  drawn  down  with  the  forceps,  so 
as  to  bring  the  pedicle  into  view  before  dividing  it ;  and  that  if  it 
be  divided  while  situated  in  the  vagina,  the  instruments  employed 
are  apt  to  injure  the  vaginal  walls  and  neighboring  tissue. 

660.  If  this  method  is   adopted,    the  polypus   may  be   seized 
with  a   pair    of   hooked-forceps    and    brought    down    so    that    its 
pedicle  may  be  divided  externally.      Or  it  may  be  divided  in  situ 
with    a    pair    of     curved    scissors,    or    a    blunt-pointed 
bistoury,    carefully    guarding    the    instrument  with    a 

finder     introduced    into    the    vagina.      Or    the    curved 

~  O 

knife,  or  polypotome  of  Dr.  Simpson,  may  be  used. 
This  last  instrument  is  in  the  form  of  the  usual  mid- 
wifery hook.  It  consists  of  a  metallic  shaft,  six  inches 
in  length,  one  extremity  of  Avhich  is  bent  into  a  hook, 
about  an  inch  in  diameter.  This  hook  is  made  of  well 
tempered  steel,  and  its  concave  surface  is  formed  into 
a  sharp  cutting  edge.  The  point  of  the  hook  is  blunt, 
to  prevent  any  injury  of  the  tissues.  Its  other 
extremity,  forming  a  wooden  handle,  four  inches  long; 
the  whole  length  of  the  instrument  being  ten  inches. 
(See  Fig.  32).  Dr.  Simpson  says  :  In  employing  this 
polypotome,  the  stalk  of  the  polypus  is  first  to  be 
reached  by  the  apex  of  the  first  finger  of  the  right 
hand,  introduced  along  the  short  anterior  or  pubic  sur- 
face of  the  vagina ;  the  instrument  is  then  pushed  by  the 
left  hand  along  this  finger  as  a  guide,  and  passed  over 
or  above  the  peduncle  of  the  tumor,  in  such  a  direction 
that  the  concavity  of  the  hook,  will  come  down  upon 
and  embrace  this  peduncle,  as  the  instrument  is  pulled  FIG.  32. 
downward.  The  next  step  is  to  make  the  blade  of  thep°'y^™e0°fDr 


320  DISEASES      OF     TTOMEN. 

polypus-knife  cut  through  the  stalk  of  the  tumor.  For  this 
purpose,  a  little  simple  traction,  with  a  slight  rolling  or  sawing 
motion,  is  all  that  is  generally  required.  If  the  tissue  of  the 
peduncle  is  dense  and  strong,  the  dividing  force  of  the  instrument 
may  be  increased  by  the  fore-finger  of  one  hand  being  applied 
with  a  traction  power  to  the  blunt  extremity  of  the  instrument, 
while  the  handle  is  dragged  down  and  moved  in  a  sawing 
direction,  by  the  other  hand  of  the  operator.  Sometimes,  when 
the  polypus  is  round  and  loose,  after  the  curve  or  hook  is  applied 
to  its  pedicle,  the  cutting  portion  of  the  polypotome  will  divide 
this  stalk  most  readily,  by  merely  doubling  backward  with  the 
fingers  the  body  of  the  polypus  upon  its  own  stalk,  and  pulling 
the  knife  against  the  bent  peduncle." 

661.  He  states  that,  during  the  last  few  years,  he  has  removed 
a  very  considerable  number  of  uterine  polypi  of  diiferent  sizes, 
and  some  of  them  of  large  dimensions,  in  this  manner ;  and  that 
he  can  speak  from  somewhat  extensive  experience  of  the  perfect 
facility  and  safety  of  its  employment. 

662.  Caustic. — There  are  very  few  if  any  cases  in  which  the 
disorganization  of  the  polypus  by  caustic  can  be  used  with  better 
results  than    the   methods  already  described.     Still,  some    cases 
may  present  themselves  in  which  it  might  be  used  with  advantage. 
The  directions  given  for  the  application  of  the  caustic  in  cancer 
uteri  would  be  applicable  here,  and  the  same  precautions   should 
be  observed  in  its  use. 


NEURALGIA     OF     THE     UTERUS. 


CHAPTER     X. 


HYSTERALGIA,  OR  NEURALGIA  OF  THE  UTERUS. 

663.  By  neuralgia  of  the  uterus  we  understand  a  painful  state 
of  that  organ,  not  preceded  or  occasioned  by  any  other  disease. 
It  is  for  the  uterus  what  gastralgia  is  for  the  stomach.     It  occurs 
in   females   during   the   period   of  existence   of  the  reproductive 
functions — say  from  fifteen  to  forty-five  years  of   age.     It  may 
occur  in  girls  before  they  reach  the  age  of  puberty,  or  in  women 
after  the  cessation  of  the  catamenia,  though  these  cases  are  very 
rare.     Two  varieties  of  this  disease    are    described ;    the  first — 
hysteralgia — is,  in  nearly  every  instance,  periodical  in  its  char- 
acter, occurring  either  at  regular  or  irregular  periods  ;  the  patient 
being  entirely  free  from  pain  in  the  intervals.    The  second  variety 
might  be  called  the  chronic  stage  of  the  disease.     It  was  first 
described  by  Dr.  Gooch,  under  the  title  of  "  irritable  uterus."     In 
this  the  periodical  character  of  the  disease  has  disappeared;  the 
patient  complaining   of  an    almost    constant   pain  in  the  uterus, 
which  is  very  sensitive  to  the  touch. 

664.  Symptoms. — In  real   uterine  neuralgia,  says  Dr.  Bennet, 
the    pain  is  principally  situated  in  the  uterus  itself,  to  which  it 
is    referred   by  the    patient   throughout  the  attack.     This    pain, 
generally  speaking,  comes  on  suddenly,  without  being  preceded 
by   any   premonitory  symptom,  unless  it  be   a   slight  numbness. 
A  few  minutes  before  and  after  the  attack,  the  patient  may  be 
perfectly  well  and  free  from  pain  ;  whereas,  during  its  existence, 
she  is  often  rolling  in  agony  on  the  bed  or  on  the  floor.     Real 
neuralgia  is  essentially  intermitting  in  its    character ;    returning 
for  a  limited  time,  at  stated   intervals,  during    the    twenty-four 
hours.     Sometimes  the  attacks  occur  only  once   in   the   twenty- 
four  hours ;  sometimes  oftener.     They  last  from  an  hour  or  two  to 
ten  or  twelve.     An  attack  is  composed  of  a  series  of  paroxysms, 

21 


322  DISEASES    OF    "WOMEN. 

each  of  which  is  followed  by  a  period  of  comparative  freedom,  of 
variable  duration.  During  the  attack,  pains  are  also  felt  in  the 
lumbo-dorsal,  ovarian,  and  other  uterine  regions  ;  and  there  may 
be  exquisite  cutaneous  sensibility  of  the  entire  abdominal  region. 
All  these  pains,  however,  disappear,  along  with  the  uterine  tor- 
mina, as  soon  as  the  attack  ceases.  The  patient  then  rallies, 
and,  in  some  cases,  looses  so  completely  all  painful  sensation, 
that  were  it  not  for  the  recollection  of  the  past,  and  the  fear  of 
the  future,  she  would  scarcely  know  there  was  any  thing  amiss 
with  her.  On  examining  a  patient  who  presents  these  symptoms 
during  the  interval  of  the  attack,  the  cervix  and  body  of  the 
uterus  are  sometimes  found  healthy  and  free  from  all  morbid 
sensibility.  Occasionally,  however,  some  lesion  is  discovered, 
which  is  evidently  the  origin  of  the  neuralgic  symptoms ;  such  as 
a  fibrous  tumor  developed  in  the  tissue  of  the  uterus,  or  an 
ulcerated  state  of  the  cervix.  In  these  cases,  we  find  the  neuralgic 
attacks  coexisting  with  the  symptoms  which  are  peculiar  to  these 
morbid  states. 

665.  According  to  Dr.  Gooch,  a  patient  who  is  suffering  from 
"  irritable  uterus,"  complains  of  pain  in  the  lowest  part  of  the 
abdomen,  along  the  brim  of  the  pelvis,  and  often  also  in  the  loins. 
The  pain  is  worse  when  she  is  up  and  taking  exercise,  and  less 
when  she  is  at  rest  in  the  horizontal  posture;  in  this  respect 
it  resembles  that  of  prolapsus  uteri ;  but  there  is  this  difference : 
that,  in  the  latter,  if  the  patient  lies  down,  she  soon  becomes  quite 
easy ;  but,  in  the  complaint  of  which  I  am  speaking,  the  recum- 
bent posture,  although  it  diminishes,  does  not  remove  the  pain. 
It  is  always  present  in  some  degree,  and  severe  paroxysms  often 
occur,  although  the  patient  has  been  recumbent  for  a  long  time. 
If  the  uterus  is  examined,  it  is  found  to  be  exquisitely  tender ; 
the  finger  can  be  introduced  into  the  vagina,  and  pressed  against 
its  sides  without  causing  uneasiness ;  but  as  soon  as  it  reaches 
and  is  pressed  against  the  uterus,  it  gives  exquisite  pain.  This 
tenderness,  however,  varies  at  different  times,  according  to  the 
degree  of  pain  which  has  been  latterly  experienced.  The  neck 
and  body  of  the  uterus  feels  slightly  swollen ;  but  this  condition 
also  exists  in  different  degrees;  sometimes  sufficiently  manifest, 


NEURALGIA  OF  THE  UTERUS.         323 

sometimes  scarcely  or  not  at  all  perceptible.  Excepting  this 
tenderness,  and  occasionally  this  swelling,  or  rather  tension,  the 
uterus  feels  perfectly  natural  in  structure  ;  there  is  no  evidence 
of  scirrhus  of  the  neck  ;  the  orifice  is  not  misshapen  ;  its  edges 
are  not  indurated.  The  patient,  finding  her  pain  greatly  increased 
by  rising  and  walking,  soon  learns  to  relieve  herself  by  lying  on 
the  sofa,  and  at  length  spends  nearly  her  whole  time  there. 
Notwithstanding  this  precaution,  there  is  always  a  considerable 
degree  of  uneasiness ;  but  this  frequently  increases  to  severe 
pain.  These  paroxysms  generally  come  on  either  a  few  days 
before  menstruation,  or  (as  is  the  case  in  many  instances)  a 
few  days  afterward.  If  the  paroxysm  is  properly  treated,  it 
subsides  in  a  few7  days  to  the  ordinary  and  more  moderate 
uneasiness.  While  this  uneasiness  is  felt  in  the  substance  of 
the  uterus,  the  general  circulation  is  but  little  disturbed.  The 
pulse  is  soft,  and  not  much  quicker  than  is  natural ;  but  it  is 
easily  quickened  by  the  slightest  emotion.  In  a  few  instances, 
however,  there  has  been  a  greater  and  more  pcrmament  excite- 
ment of  the  general  circulation ;  the  degree  in  which  the  health 
has  been  reduced,  has  been  different  in  different  cases.  A  patient 
who  was  originally  delicate,  who  has  suffered  long,  and  has  used 
much  depleting  treatment,  has  been  (as  might  reasonably  be 
expected)  the  most  reduced;  she  has  grown  thin,  pale,  weak,  and 
nervous ;  menstruation  often  continues  regular,  but  sometimes 
diminishes,  or  ceases  altogether ;  the  functions  of  the  stomach 
and  bowels  are  not  more  interrupted  than  might  be  expected  from 
the  loss  of  air  and  exercise  ;  the  appetite  is  not  good,  and  the 
bowels  require  aperients;  yet  nothing  more  surely  occasions  a 
paroxysm  of  pain  than  an  active  purgative. 

666.  Diagnosis. — In  the  first  variety  of  uterine  neuralgia,  the 
periodicity  of  the  disease  will  serve  to  distinguish  it  from   any 
organic  affection  of  the  uterus :  for  where  the  disease  involves  a 
change  of  structure,  the  pain  and  uneasiness  are  continuous,  there 
being  no  perfect  intermissions. 

667.  It  may  be  distinguished  from  inflammation  of  the  cervix 
uteri  by  the  absence  of  swelling,  heat,  redness,  and  especially 


324  DISEASES     OF     WOMEX. 

the  dilatation  of  the  os  uteri,   and  the  muco-purulent  secretion,, 
which  are  almost  pathognomonic  of  this  affection. 

668.  From   neuralgic  dysmenorrliea,  by  the    pain    and   other 
symptoms  continuing  throughout  the  menstrual  interval,  instead 
of  ceasing  with  the  catamenia. 

669.  From  prolapsus  uteri,  for  which  it  would  be  most  likely  to 
be  mistaken,  owing  to  the  increased  suffering  when  in  an  upright 
position,  by  a   vaginal   examination,   the   uterus  being  found  in 
situ. 

670.  Treatment. — Neuralgia  of  the  uterus  may  be    distinctly 
periodic  in   character,  and   in   malarial  regions  will   require  the 
treatment  of  a  masked   ague.     The  patient  is  carefully  prepared 
for  the  use  of  quinine,  if  any  thing  needs  be  done,  and  the  agent 
is  then  given  to  the  extent  of  twelve,   fifteen,  or  even    twenty 
grains,   during  the  intermission  or  remission.     In    place  of  the 
quinine,  we  may  sometimes  use  the  carbazotate  of  ammonia,  in 
doses  of  from  one-eighth  to  one-half  grain,  for  a  cure. 

671.  When  it  is  not  periodic  we  make  a  careful  examination  of 
the  case  to  determine  the  indications  for  remedies,  for  the  pain 
yields  to  the  right  remedy,  if  we  can  find  it.     In  some  cases  the 
Aconite  with  Macrotj's  will  reach  the  case,  the  pulse  showing  ex- 
citation.    In   others  the   nervousnes,  with  the  peculiar  character 
of  the  pain  (tensive)  calls  for  Pulsatilla  and    Macrotys.     When 
the  pain  has  an  expulsive  character,  give  Viburnum  alone  or  with 
Macrotys.     If  there  is  heaviness  and  dragging,  and  it  is  near  the 
menstrual  period,  give  Grossypium.     If  the  patient  is  dull  and  in- 
clined to  sleep,  give  Belladonna  with  Aconite.     If  there  is  scanty 
urine,  and  the  uterine  pain  is  attended  with  expulsive  efforts  of 
the  bladder,  give  G-elseminum  ;  this  remedy  is  also  indicated  by 
the  flushed  face,  bright  eyes,  and  contracted  pupils,  showing  de- 
termination of  blood  to  the  brain.     Rhus   is  indicated   in   many 
cases  by  the   burning  character  of    the  pain,  as  well  as  by  the 
usual  symptoms.     Bromide  of  Potash  is  called  for  by  sexual  ex- 
citement; Bromide  of  Ammonium  by  hysterical  symptoms,  espe- 
cially involving  the  muscular  system.     Prussiate  of  Potash  may 
be  used  with  advantage  when  the  patient  is  hysterical,  suffers  se- 
verely from  want  of  rest,  and  the  mucous  membranes  are  lax  and 
pallid. 


NEURALGIA     OF     THE     UTERUS.  325 

Nux  Vomica  is  indicated  when  there  is  nausea  associated  with 
evidence  of  atony  of  the  stomach  ;  wo  also  use  it  when  the  pain 
shoots  from  the  uterus  upwards  towards  the  umhilicus.  This  has 
sometimes  heen  known  as  uterine  colic.  In  these  latter  cases  AVO 
usually  combine  the  Nux  with  Macrotys,  in  the  usual  small  doses. 

Nitric  Acid  is  an  excellent  remedy  when  the  tongue  shows  the 
peculiar  violet  coloration,  whether  the  disease  is  periodic  or  not. 
iodide  of  Potassium  is  the  remedy  when  the  tongue  is  express- 
ionless and  of  a  leaden  pallor.  (This  case  may  or  may  not  he 
syphilitic,  but  the  remedy  is  equally  good  in  either.)  Arsenicuin 
may  be  used  when  the  pulse  is  soft  and  feeble,  and  the  skin  ex- 
pressionless, the  dose  being  small. 

672.  In  other  cases  we  find  an  associate  wrong  of  the  digestive 
organs  and  of  the  blood,  and  we  get  (lie  indications  for  treatment 
from  the  tongue.     There  is  a  case  in  which  we  find  most  marked 
advantage  from  the  use  of  Sulphite  of  Soda — the   tongue  being 
broad,  pallid  and  dirty — and  still  there  is  a  worse  case,  in  which 
the  very  dirty  tongue,  with  weight  and  fullness  in   the  epigastric 
region,  calls   for  an   emetic.     The  fullness  of  tongue,  fullness  of 
tissue,  venous  fullness,  and  dizziness,  call  for  Podophyllin,  either 
in  large  or  small  doses. 

673.  When   we  see   no  indication   for  a    specific  remedy,    we 
may  use  the   hypodermic   injection  of  morphia,  or  may  use  it  in 
any  case  where  the  pain  is  so  severe  as  to  demand  prompt  relief. 
I  use  a  solution  often  grains  of  sulphate  of  morphia  to  the  ounce 
of  water — the  quantity  necessary  to  relieve  the  pain  being  from 
ten  to  thirty  drops — fifteen  drops  may  be  considered  the  medium 
dose.     I  prefer  to  insert  the  injection   near  the  seat  of  the  pain, 
and  in  this  case  the  upper  part  of  the  thigh  or  the  abdomen  would 
be  best,  but  modesty  will  usually  cause  us  to  put  it  in  the  arm.     I 
prefer  the  hypodermic  injection  in  this  case  to  either  chloral  or 
morphia  used  internally,  though  it  must  not  be  continued  to  form 
a  habit.     The  object  should  be,  in  all  cases,  to  mitigate  local  suf- 
fering, and  to  sustain  and  improve  the  general  health,  as  the  dis- 
ease is  tedious  of  cure,  and  liable  to  relapse. 

674.  I  may  report  one  case  of  this   disease.     It  presented  all 
the  symptoms  heretofore  described,  though  not  in  such  an  aggra- 
vated degree.     No  structural  disease  could  be  discovered  by  the 
closest  examination.     In  this  case  I  directed  the  use  of  the  hand- 


326  DISEASES     OF      WOMEN. 

bath  every  morning,  commencing  with  water  agreeably  warm,  and 
gradually  cooling  it,  until  quite  cold  water  could  be  used  ;  these 
baths  were  followed  by  brisk  and  long-continued  friction,  suf- 
ficient to  redden  the  skin  and  bring  the  circulation  to  the  surface. 
At  first,  she  could  hardly  bear  the  weight  of  the  hand  over  the 
hypogastric  region,  but  by  continuing  the  friction,  the  sensibility 
gradually  decreased.  Vaginal  injections  were  used,  with  the 
pump-syringe,  morning  and  night.  The  water  was  used  at  first 
tepid,  but  afterward  quite  cold.  The  bowels  were  kept  regular 
by  injections  of  warm  water. 

675.  During  the  entire  treatment  she  took  three  of  the  follow- 
ing pills  a  day  : 

R    Iodine,  gr.  v. 

Extract  of  Nux  Vomica,  gr.  iij. 
Macrotin,  gr.  xv. 

M.  Ft.  Pillula,  xx.  To  relieve  the  constant  pain  in  the  small 
of  the  back,  an  irritating  plaster  was  applied,  and  worn  for  two 
or  three  weeks  intermittingly  ;  it  produced  counter-irritation,  but 
was  never  left  on  sufficiently  long  to  produce  suppuration.  To 
improve  the  general  health,  the  hydrastin,  prae-carbonate  of  iron, 
and  ale,  were  first  administered  ;  as  this  lost  its  effect,  it  was 
changed  for  hydrastis  canadensis,  prussiate  of  iron  and  tincture 
of  xanthoxylum,  and  then  to  the  compound  tincture  of  Peruvian 
bark  and  iron.  Under  this  treatment  a  marked  improvement  of 
the  general  health  could  be  noticed  in  a  short  time,  and  as  this 
improvement  progressed,  the  local  difficulty  likewise  became 
ameliorated.  The  treatment  was  continued  for  some  two  months, 
and  resulted  in  a  perfect  cure,  the  lady  having  had  no  relapse 
since.  In  reference  to  the  means  employed,  she  ascribed  the 
cure  principally  to  the  daily  baths,  and  especially  to  the  friction 
over  the  hypogastrium,  as  she  always  felt  much  better  after  it. 

RHEUMATISM  OP  THE  UTERUS. 

676.  Rheumatism  of  the  womb  may  occur  in  the  non-pregnant 
female,  but  it  is  much  oftener  met  with  during  pregnancy.     It 
may  arise  at  any  stage  of  gestation,  but  it  is  much  more  frequent 


RHEUM  A  T  ISM     O  F     T  1 1 E     U  T  E  K  U  S .  327 

toward  the  termination,  when  the  uterus  has  acquired  its  maxi- 
mum enlargement.  Any  part  of  the  uterus  is  liable  to  the 
affection;  thus,  it  may  affect  and  be  confined  to  the  cervix,  body, 
or  fundus  of  the  organ,  or  the  entire  uterus  may  suffer  from  it. 
With  the  affection  of  the  uterus  there  sometimes  exists  a  general 
affection  of  the  same  nature,  involving  other  portions  of  the  body 
but,  most  generally,  the  uterus  arid  the  pelvic  viscera  adjacent, 
are  the  only  parts  affected.  Like  rheumatism  of  any  other  part 
of  the  body,  there  is,  frequently,  a  metastasis  of  the  pain  from 
one  part  of  the  organ  to  another,  or  to  the  adjacent  parts,  or  to 
some  distant  part  of  the  system,  or  it  may  disappear  suddenly, 
again  recurring  at  a  longer  or  shorter  interval. 

677.  Causes. — The    causes    that    produce    rheumatism    of  the 
uterus  are  the  same  that  would  produce  the  disease  in  any  other 
portion  of  the  system;  as  exposure  to  cold,  atmosperical  changes, 
especially  to  a  sudden   chill  when  overheated,  as  by  sitting  in  a 
draught  of  air,  or  in  some  damp  place,  as  a  cellar,  etc.     According 
to  M.  Cazeaux  there  is  one  cause  peculiar  to  the  malady  under 
consideration.     This  is  the  facility  with  which  this  organ,  under 
the  thinned  integuments  of  the  abdomen,  feels  the  impression  of 
cold   in   the   latter  months   of  pregnancy ;    the    abdomen    being 
guarded,  where  it    incloses   the  uterus,  only  by  extremely  light 
garments,  which  are  closely  in  contact  with   it,  and  the  lumbo- 
sacral  region  being  often  badly  protected  by  jackets  of  insufficient 
length. 

678.  Symptoms. — According  to  the  same  author,  "rheumatism 
of  the  womb  often  attacks  persons  constitutionally  predisposed  to 
nephritis.     It  may  coexist  with  a  general  affection  of  the  same 
nature  ;    but,  in  a  majority  of  cases,  the   uterus  alone,  and  the 
adjacent  structures  are  the  seats  of  the  disorder.     It   has,  beside, 
been  frequently  found  to  be  a  consequence  of  the  sudden  cessation 
of  rheumatic  pain,  originally  situated  in  some  other  part  and  sud- 
denly transposed  to  the  womb.     Whatever  may  be  the  mode  of  its 
onset,  the  disorder  is  easily  recognized  by  very  decided  charac- 
teristic features.     Its  principal  symptom  is  pain  ;  where  not  the 
least  violence  has  been  offered  to  the  organ,  the  womb  becomes 
the  seat  of  general  or  partial  pain,  the  intensity  of  which  varies 


328  DISEASES     OF     WOMEN. 

from  the  slightest  sense  of  weight  up  to  the  most  insupportable 
agony.  It  may  affect  the  uterus  wholly,  or  only  attack  some 
particular  part  of  it,  as  the  orifice,  the  fundus  or  the  cervix. 
Where  rheumatism  is  fixed  in  the  fundus  only,  the  pain  is  felt  in 
the  region  above  the  umbilicus.  It  is  increased  by  pressure,  by  the 
contraction  of  the  abdominal  muscles,  and  sometimes  by  the  mere 
weight  of  the  clothes ;  the  patient  is  often  unable  to  move  ;  if  the 
disorder  is  situated  lower  down,  there  are  shooting  pains  that  run 
from  the  loins  toward  the  pelvis,  the  thighs,  the  external  genitals, 
and  the  sacral  region,  along  the  ligaments  of  the  uterus.  Lastly, 
when  the  cervix  is  the  affected  part,  it  may  be  known  by  the 
vaginal  touch,  which  gives  rise  to  excessive  suffering.  But  of  all 
the  causes  that  serve  to  exasperate  the  pain,  none  is  so  distressing 
as  the  incessant  motions  of  the  child. 

679.  "  Like    other  rheumatic  pains,  those   of   the  womb  are 
movable,  and  are  observed  occasionally  to  pass  suddenly  from  one 
portion  of  the  organ  to  another.     They  often  suddenly  cease  and 
proceed  to  attack  some  other  organ.     This  is  most  apt  to  happen, 
where  the  uterine  rheumatism  has  been  preceded  by  a  fixed  pain 
of  some  other  part  of  the  body,  and  where  remedies  are  in  use 
calculated  to  recall  the  pain  to  its  original  seat. 

680.  "  These  pains  are  characterized  by  frequent  exacerba- 
tions that  are  variable   as   to  duration   and  intensity,  according 
to  the  stage  of  the  malady ;    they  are  succeeded  by  remissions, 
during  which  the  patient  scarcely  complains  of  a  vague  sense 
of  pain. 

681.  "  The  pains  of  uterine  rheumatism  are  generally  attended 
with  a  degree  of  recto-vesical  tenesmus,  which  is  violent  in  pro- 
portion to  the  severity  of  the  pains  and  the  approximation  of  the 
seat  of  the  rheumatism  to  the  lower  segment  of  the  organ.     In 
such  cases  the  patient  is  tormented  by  perpetual  desire  to  urinate. 
The  discharge  of  urine  is  accompanied  with  smarting  pain,  some- 
times with  severe  pains,  and  in  some  instances  the  discharge  can 
not  be  effected  at  all.     The  efforts  to  discharge  the  contents  of  the 
rectum  are,  in  some  cases,  equally  fruitless. 

682.  "  Pains  of  such  violence,  situated  in  an  organ  so  import- 
ant, must  of  necessity,  produce  a  pretty  severe  general  reaction. 


RHEUMATISM     OF     THE     UTERUS.  329 

The  disorder,  like  most  of  the  inflammatory  diseases,  generally 
commences  with  a  slight  rigor,  which  lasts  fifteen  or  twenty 
minutes.  The  succeeding  fever  diminishes,  or  may  even  wholly 
cease  during  the  interval  between  the  attacks,  yet,  while  they  last, 
it  is  commonly  quite  severe  ;  the  pulse  is  hard  and  frequent,  the 
face  flushed  and  excited,  the  tongue  red  and  dry,  the  thirst  urgent; 
the  skin  is  hot,  and  the  patient  is  often  found  to  be  extremely 
agitated  and  restless.  Toward  the  close  of  the  paroxysm,  there 
frequently  supervenes  a  copious  sweat,  which  seems  to  be  the 
harbinger  of  a  decided  improvement.  After  this,  these  general 
symptoms  are  appeased,  together  with  the  uterine  pains,  only  to 
reappear  with  them,  after  the  lapse  of  a  few  hours,  or  even  of 
several  days." 

683.  Two  very  important  points  yet  remain  for  investigation, 
viz :  the  influence  of  rheumatism  on  the  progress  of  pregnancy, 
and  its  influence  upon  labor.  M.  Cazeaux  says :  "  Though  the 
attacks  have  persisted  for  a  length  of  time,  or  when  they  have 
"been-  very  violent,  they  are  followed  by  uterine  contractions,  and 
may  in  this  way,  bring  on  premature  delivery.  In  such  a  case, 
the  patient  suffers  from  severe  tensive  pain.  This  tension  is  not 
equable,  for  it  rises  to  a  great  hight,  and  then  subsides — to  begin 
again  and  pursue  the  same  course  at  different  intervals.  At  first, 
the  womb  becomes  partially,  and  afterward  universally  hardened, 
during  the  pain.  The  cervix  becomes  rigid  and  partially  dilated, 
but  its  dilatation  is  at  first  slow  and  difficult,  and  its  subsequent 
progress  does  not  correspond  with  the  pace  of  the  pains.  The 
abortion  with  which  she  is  now  menaced,  is  more  likely  to  take 
place  in  the  febrile  than  in  the  apyrectic  form  of  the  disease. 
Indeed,  abortion  is  not  so  common  an  occurrence  in  the  case  as 
might  be  presumed.  In  some  instances  the  os  uteri  has  been 
observed  to  dilate  to  the  extent  of  three-fourths  of  an  inch  or  an 
inch  and  a  quarter  in  diameter,  the  bag  of  waters  has  been 
formed,  and  afterward  withdrawn  little  by  little,  the  orifice  closing 
again,  and  all  symptoms  of  labor  wholly  disappear.  So  long  as 
the  diameter  of  the  os  uteri  does  not  reach  the  extent  of  five 
centimeters,  we  may  reasonably  hope  to  put  off  the  labor.  These 
uterine  rheumatic-pains  may  simulate  labor-pains,  and  lead  to 


330  DISEASES    OF    WOMEN. 

the  belief  that  they  are  real  labor-pains,  when,  in  fact,  they  are 
not  so. 

684.  "An  attack  of  uterine  rheumatism  generally  retards  the 
progress  of  a  labor,  and  sometimes  even  renders  the  spontaneous 
expulsion  of  the  foetus  wholly  impossible.  In  addition  to  the 
general  phenomena  I  have  described,  there  are  here  some  special 
ones  to  be  met  with  :  1.  It  is  well  known  that  a  normal  contrac- 
tion does  not  begin  to  be  painful,  until  it  has  accomplished  the 
greater  part  of  its  task,  and  is  in  the  act  of  dilating  and  distend- 
ing the  os  uteri;  in  other  words,  the  true  pains  of  labor  do  not 
begin  until  the  force  of  the  body  of  the  womb  begins  to  overcome 
the  resistance  of  the  cervix.  In  rheumatism  of  the  womb,  on 
the  contrary,  the  uterine  contraction  is  painful  from  the  com- 
mencement, and  before  the  least  power  is  exerted  upon  the  neck, 
so  that  the  cause  of  the  pain  is  not  in  the  violent  distension  of 
the  orifice,  but  in  the  contraction  itself,  in  other  morbid  circum- 
stances, and  in  other  relations  of  the  nerves  and  contractile  fibers 
of  the  uterus.  2.  In  natural  labor,  the  contractions  commence  at 
the  fundus  uteri,  and  are  directed  toward  the  lower  segment.  In 
rheumatism,  instead  of  commencing  at  the  fundus,  they  commence 
at  the  painful  point,  and  run  toward  the  neck  in  an  irregular 
manner.  Again,  the  pains  exist  before  the  contractions  of  the 
womb;  and  under  their  influence,  when  they  are  established, 
acquire  a  high  degree  of  intensity.  Its  violence  sometimes 
arrests  the  contractions  before  they  have  run  through  their  ordin- 
ary cycle.  They  are  in  such  a  case  brisk,  short,  and  grow  less 
and  less  frequent.  3.  Toward  the  close  of  the  labor,  when  the 
action  of  the  womb  requires  to  be  sustained  by  the  voluntary 
contraction  of  the  abdominal  muscles,  the  woman  for  fear  of 
increasing  her  sufferings,  refrains  from  contracting  her  abdominal 
muscles,  Avhich  causes  the  labor  to  be  excessively  slow.  The 
patient  is  in  a  state  of  extreme  anxiety ;  the  frequent  pulse,  the 
hot  skin,  the  thirst,  the  urinary  tenesmus,  are  much  augmented. 
When  the  sufferings  are  too  much  protracted,  she  at  last  falls  into 
a  collapse  (which  is  often  a  fortunate  event,)  during  which  the 
pain  is  suspended.  Under  these  circumstances,  a  profuse  sweat 
has  been  observed,  which  has  had  the  happiest  effect  on  the  rest 


RHEUMATISM     OF     THE     UTERUS.  331 

of  the  labor.  But  in  other  instances,  the  womb  grows  more  and 
more  painful ;  it  is  rather  in  a  state  of  permanent  contraction  or 
fibrillar  vibration,  than  of  real  contraction ;  the  pulse  becomes 
accelerated,  and  then  the  woman  is  under  the  influence  of  a 
metritis  which  renders  the  labor  extremely  painful." 

685.  The  painful  effects  of  uterine  rheumatism  do  not  always 
terminate  with  delivery.     The  contraction  of  the  organ  is  slow 
and  incomplete,  the  uterine  vessels  are  less  compressed,  and  hence 
copious  flooding  may  occur.     The  after  pains  are  very  severe,  and 
continue  for  a  long  time,  the  lochial  discharge  is  diminished  in 
quantity,    and    the    secretion    of    milk    is    often    scanty.      The 
persistence  of  abdominal  pain,  added  to  the  symptoms  of  general 
reaction,  might  lead  to  the  diagnosis  of  peritoneal  inflammation, 
though  none  such  should  really  exist. 

686.  Diagnosis. — It   is    important    to    distinguish  rheumatism 
from   inflammation,  and  this  is  sometimes  very  difficult.     If  the 
patient  have  had  previous  attacks  of  rheumatism,  especially  if 
they  have  just  preceded  the  uterine  disease,  and  ceased  shortly 
before,  or  on  its  appearance,  we  will  have  good  grounds  to  suspect 
the   character  of   the   disease.     Rheumatism,   also,  as  a  general 
rule,  sets  in  more  quickly,  and  is  paroxysmal  in  character.     It  is 
also  said  that  the  difference  may  be  detected  by  the  vaginal  touch. 
In  both  diseases  the  uterus  is  painful  to  the  touch,  but  in  inflam- 
mation the  pain  continues  as  long  as  the  finger  is  applied  to  it, 
while    in    rheumatism,  if   the   organ   is    slowly  raised    with   the 
fingers,  the  pain  either  ceases  wholly,  or  is  much  mitigated  by 
taking  off,  in  this  way,  the  tenesmus   uteri.     It  may  be  distin- 
guished from  neuralgia  of  the  uterus,  by  the  periodic  character 
of  the  pain  in   this  last  disease,  and   by  the  remissions    being 
longer  and  more  decided ;  the  abdomen  is  not  so  generally  tender, 
nor  is  the  constitutional  suffering  so  great. 

687.  Treatment. — The  treatment  of  rheumatism  of  the   uterus 
will  be  very  like   the  treatment  of  rheumatism  elsewhere — no 
single  remedy,  however  good,  being  sufficient  to  relieve  all  cases. 
It  is  true,  however,  that  the  group  of  anti-rheumatics  influencing 
the  reproductive  organs   and  functions  are  more  general!}-  indi- 
cated than   the  others.     Of  these  the  Macrotys  holds  the  first 


332  DISEASES     OF     WOMEN. 

place,  and  deserves  the  careful  study  of  the  physician.  In  rheu- 
matism occurring  during  pregnancy  it  is  par  excellence  the  rem- 
edy, unless  it  should  be  a  very  severe  attack,  or  a  metastasis  of 
the  disease  from  some  other  part.  In  the  majority  of  cases,  the 
weight,  dragging,  tenderness,  annoying  pain  as  of  contraction, 
sometimes  simulating  labor  pains,  are  speedily  relieved  by  this 
remedy.  The  extreme  tenderness  or  irritability  of  the  organ, 
sometimes  met  with,  is  not  relieved  so  speedily,  and  may  require 
additional  remedies.  I  usually  pi-escribe  the  Macrotys  with  Aco- 
nite if  there  is  the  slightest  evidence  of  fever,  as — 
&  Tinct.  Aconite,  gtt.  v.  to  gtt.  x. 

Tinct.  Macrotys,  gtt.  xxx.  to  5j. 

Water,  5iv.  M. 

A  teaspoonful  every  hour  to  three  hours. 

688.  When  the  extremities  are  cool,  the  surface  pallid,  and  the 
abdomen  tumid  and  relaxed,  especially  if  associated  with  colicky 
pains,  I  give  Nux  in  place  of  the  Aconite.     Bryonia  is  the  rem- 
edy, and  may  be  given  alone,  with  the  Aconite,  or  with   the  Ma- 
crotys, when  the  pains  are  sharp,  lancinating,  evidently  perito- 
neal.    It  is  also  suggested  when  the  patient  coughs,  and  has  some 
pleuritic  pain.     Apocynum  is  to  be  thought  of  when  the  patient 
has  swollen  feet,  puffed  eyelids,  redness  of  the  labia,  or  inclination 
to  menorrhagia.     Viburnum  is  always  to  be  thought  of  as  a  rem- 
edy in  rheumatism  during  pregnancy,  when  there  is  threatened 
abortion  ;  it  may  be  combined  with  either  of  the  others  named. 
Sticta  Pulmonaria  becomes  a  valuable  remedy  when   the  patient 
complains  of  pain  and  soreness  in  the  shoulders  and  back  of  the 
neck,  extending  to  the  occiput,  and  sometimes  with  a  most  un- 
pleasant cough.     The  Eupatorium  Perf.  is  a  good  remedy  when 
the  pains  are  dull  and  heavy,  with  pressing  down  in  the  region 
of  the  bladder  and  difficult  micturition.     It  may  be  given  with 
Aconite  or  with  Macrotys,  as — ' 

R     Tinct.  Eupatorium,  gtt.  xx. 
Tinct.  Macrotys,  3ss. 
Water,  |iv.  M. 

A.  teaspoonful  every  hour. 

689.  In  acute  inflammatory  rheumatism,  if  the  special  indica- 
tions named  above  are  not  present,  I  would  advise  a  trial  of  Sal- 
icylic Acid,  following  with  the  Macrotys  as  soon  as  the  pain  is 
relieved.     It  may  be  given  in  pill  form,  adding  Glycerine  to  the 


DISPLACEMENTS     OF     THE     UTERUS.  333 

Salicylic  Acid  and  a  small  portion  of  Borax,  until  of  the  consist- 
ence of  a  pill  mass  — making  four  or  five  grain  pills,  and  givino- 
one  every  hour  or  two  until  relief  is  obtained.  Or  we  may  use 
the  remedy  in  solution,  as — 

R     Salicylic  Acid,  3ij. 

Acetate  of  Potash,  gij. 
Distilled  Water,  .sij.          M. 
A  teaspoonful  every  two  or  three  hours. 

690.  My  experience  proves  to  me  that  if  the  remedies  named 
be  used  during  the  latter  months  of  pregnancy,  when  the  patient 
is  suffering  from  unpleasant  sensations  in  the  uterus,  due  to  rheu- 
matism, we  will  not  have  the  serious  trouble  sometimes  met  with 
during  labor.  The  Macro tys  alone  will  meet,  the  most  of  these 
cases,  and  is  a  true  partus  prcparator.  Even  when  the  case  is  first 
seen  during  the  progress  of  the  labor,  I  should  expect  very  satis- 
factory results  in  mitigating  false  pain,  and  relieving  irrritation. 


CHAPTER    XI. 


DISPLACEMENTS  OF  THE  UTERUS. 

691.  Under  this  head  we  have  to  consider  prolapsus  uteri,  or 
the  displacement  of  the  uterus  downward ;  retroversion  and  retro- 
flexion^  or  the  displacement  of  the   fundus   uteri  backward,  the 
cervix  being  thrown  forward,  or  remaining  in  situ  ;  anteversion 
and  anteflexion,  or  the  displacement  of  the  fundus  forward,  the 
cervix  being  thrown  backward,  or  remaining  in  situ  ;  and  inver- 
sion of  the  uterus,  or  where  the  uterus  is  turned  inside  out,  the- 
fundus  and  body  of  the  womb  descending  through  the  os,  the 
mucous  membrane  being  external.     In  all  these  displacements  the 
position  of  the  uterus  may  be  changed  but  slightly,  or  it  may  be 
completely  displaced,  or  it  may  vary  in  degree  from  one  to  the 
other. 

692.  When  we  consider  the  anatomical  relations  of  this  organ, 
and  the  structures  which  support  and  keep  it  in  its  proper  posi- 


334  DISEASES     OF     WOMEN. 

tion,  as  well  as  the  many  changes  in  size,  weight,  and  position 
that  necessarily  take  place  during  pregnancy,  the  frequent  con- 
gestion and  enlargement  of  the  organ,  the  presence  of  tumors, 
and  the  diseased  enlargements  of  the  abdominal  and  pelvic  viscera, 
we  will  see  at  once,  that  of  all  the  organs  in  the  body,  this  is  the 
most  liable  to  displacement. 

PROLAPSE  OF  THE  UTERUS. 

693.  This    form   of   displacement  is    more   common  than  any 
other  ;  it  consists  in  a  depression  of  the  uterus  below  its  natural 
level,  and  may  exist  in  very  various  degrees.     Three  varieties  are 
named  by  authors,  according  to  the   extent   of  the  displacement. 
1,   relaxation  of  the  womb  ;  2,  prolapsus  ;  and  3,  procidentia. 

694.  The  first  variety,  or  relaxation,  may  be  called  the  incipient 
sta^e  of  the  disease,  the   uterus  having  sunk   below  its  normal 

O  f  <~3 

elevation,  toward  the  outlet  of  the  pelvis,  without,  however, 
descending  so  low  as  to  rest  on  the  perineum. 

695.  In    the    second    variety,    or    prolapsus,    the    uterus    has 
descended  nearly  or  quite  to  the  os  externum,  the  organ  resting 
on  the  perineum.     In  this  position  it  fills  the  vagina,  the  upper 
part  of  which  is  folded  upon  itself;  the  uterus,  thus  situated,  lies 
in  the  direction  of  the  axis  of  the  outlet  of  the  pelvis. 

696.  In  the  third  variety,  or  procidentia,  there  is  a  complete 
protrusion  of  the  uterus  beyond  the  vulva,  the  vagina  is  everted 
and  turned  inside   out,   forming  the  external  investment  of  the 
body  and  fundus  of  the  organ.     In  this  displacement  the  bladder 
and  rectum  are  more  or  less   involved ;  in    some  cases  of   long 
standing  the    tumor    containing    the    bladder,   a    portion    of  the 
rectum,  and  sometimes  of  the  small  intestine. 

697.  Causes. — We  have  here  first  to  consider   the   means  by 
which  the  uterus  is  supported,  and  then  we  will  be  better  able  to 
understand  the  causes  that  will  affect  the  structures  formin^  this 

O 

support,  or  the  uterus  itself,  changing  its  size  and  weight,  and  thus 
enabling  it  to  overcome  the  resistance  offered  to  its  descent.  By 
referring  to  the  anatomy  of  the  genital  organs,  it  will  be  found 
that  the  outlet  of  the  pelvis  is  closed,  first,  by  the  perineum, 
a  dense,  fibro-cellular  structure,  situated  in  the  center  of  the 


PROLAPSE     OF     THE     UTERUS.  335 

outlet,  arid  second,  by  muscles  and  fascia  which  have  one   point 
of  attachment  to  the  bony  walls  of  the  pelvis,  and  the  other  to 


FIG.  38. — PROLAPSE  OF  THE   UTERUS. 

this  central  structure,  the  perineum.  This  musculo-membranous 
structure  closing  the  outlet, .  supports  the  pelvic  viscera,  and 
antagonizes  the  action  of  the  diaphragm  and  the  abdominal 
muscles.  Through  it  passes  three  canals,  the  rectum,  vagina, 
and  urethra,  each  being  supported  below  by  the  perineum  and  the 
muscles  attached  to  it,  and  are  inclosed  above  by  the  funnel- 
shaped  muscle,  the  levator  ani.  The  vagina  lying  between  the 
rectum  and  bladder  is  compressed  between  the  two,  the  anterior 
and  posterior  walls  being  in  contact,  and  forming  a  solid  column 
instead  of  a  hollow-cylinder  ;  this  column  being  supported  below 
by  its  attachment  to  the  pubic  bones  and  perineum.  Upon  it,  at 


336  DISEASES      OF      WOMEN. 

its  upper  extremity,  rests  the  uterus,  situated  between  the  rectum 
behind  and  the  bladder  in  front.  By  carefully  examining  these 
structures,  it  will  be  seen  that  so  long  as  the  musculo-mern- 
branous  structure  closing  the  outlet  is  sufficient  to  resist  the 
action  of  the  diaphragm  and  abdominal  muscles,  and  the  vagina 
retains  its  normal  healthy  structure,  the  uterus  has  a  perfect 
support  from  below,  and  that  prolapse  cannot  occur,  as  a  general 
rule,  so  long  as  this  is  the  case.  That  the  ligaments  of  the  uterus 
do  not  contribute  but  very  little,  if  any,  to  this  support,  is  proved 
by  the  fact  that  the  organ  can  be  drawn  down  to  the  os  externum 
without  putting  them  on  the  stretch. 

698.  In  support  of  the  above  views,  several  authors  might  be 
quoted ;  Dr.  Ashwell  says :  "  Little  doubt  can  exist  in  the  minds 
of  those  who  have  carefully  studied  the  anatomy  of  the  pelvic 
viscera,  that  the  vagina,  bladder,  and  rectum,  together  with  the 
muscles  lining  the  cavity  and  forming  the  flooring  of  the  pelvis, 
have  the  principal  share  in  maintaining  the  uterus  in  its  natural 
position."  Dr.  Burns  says  :  "  By  experiments  made  on  the  dead 
subject,  we  find  that  more  resistance  is  afforded  to  the  protrusion, 
by  the  connection  of  the  uterus  and  vagina  to  the  neighboring 
parts,  than  by  the  agency  of  the  ligaments;  for,  although  the 
ligaments  be  cut,  we  can  not,  without  much  force,  make  the  uterus 
protrude.  A  debility  or  relaxation  of  the  levator  ani  and  perineal 
muscles,  but  particularly  an  extension  and  slackness  of  the  pelvic 
fascia  and  its  connection  with  the  uterus  and  vagina,  are  in 
a  great  measure  essential  to  the  production  of  prolapsus."  Dr. 
Bennet  says :  "  Prolapsus,  or  falling  of  the  uterus,  either  partial 
or  complete,  is  generally  attributed  to  laxity  of  the  uterine 
ligaments.  This  opinion  I  believe  to  be  mistaken,  and  to  be 
founded  on  an  anatomical  error.  The  uterus  is  not  so  much 
supported  and  retained  in  situ  by  its  ligaments,  as  by  the  pressure 
of  the  surrounding  organs  and  the  contraction  of  the  upper  part 
of  the  vagina  on  its  lower  segment.  The  vagina,  in  the  healthy 
state,  is  not  a  mere  open  pouch,  but  a  contractile  closed  canal, 
like  the  rectum,  which  closes  on  and  supports  the  uterine  neck, 
and,  in  my  opinion,  has,  generally  speaking,  almost  as  much  to 
do  with  the  support  of  the  uterus  as  the  uterine  ligaments 


PROLAPSE     OF     THE     UTERUS.  337 

themselves."  Dr.  Hamilton  says :  "  It  is  evident  that  the 
bladder,  the  vagina,  the  rectum,  and,  more  especially,  the  muscles 
lining  the  pelvis,  and  those  connecting  the  lower  part  of  the 
trunk  and  the  inferior  extremities,  mainly  contribute  to  hold  the 
uterus  in  its  natural  position.  It  Avill  be  found  that,  in  every 
case  of  prolapsus  uteri,  the  vagina,  or  bladder,  or  rectum,  or 
muscles  lining  the  pelvis,  or  filling  up  its  outlet,  are  debilitated,  or 
lacerated,  and  therefore  the  relaxation  of  the  peritoneum  and  its 
production  (t\ie  ligaments  of  the  uterus)  is  the  effect  of  prolapsus, 
and  not  its  cause.  Cases  of  prolapsus  in  virgins,  it  may  be 
alleged,  furnish  an  objection  to  this  reasoning.  Such  cases  may 
be  easily  explained.  The  accident  in  these  cases  is  the  effect  of  a 
sudden  exertion  in  moving  the  body,  at  a  time  when  the  usual 
supports  of  the  uterus  are  relaxed,  viz. :  during  menstruation ; 
while  that  process  goes  on,  every  part  connected  with  the  uterus 
feels  flabby  and  open  to  the  Avoman  herself,  and  any  violent  action 
of  the  locomotive  muscles,  as  in  leaping,  or  dancing,  or  running, 
must  occasion  displacement  of  the  uterus,  in  the  same  Avay  that  it 
would  force  out  a  portion  of  the  intestine,  if  the  abdominal 
muscles  Avere  Aveakcned  at  their  ring." 

699.  Another  fact  that  I  have  noticed  in  cases  of  this  disease, 
and  Avhich,  I  think,  has  an  important  bearing,  not  only  in  regard 
to  the  pathology  of  the  disease,  but  also  in  regard  to  the 
treatment,  is  the  invariably  lax  and  flaccid  state  of  the  abdominal 
muscles.  It  might  seem  strange  that  even  if  this  Avas  the  case  in 
this  disease,  it  Avould  have  any  effect  on  the  displacement,  and  Ave 
would  even  judge  from  first  sight,  that  it  would  be  rather 
favorable  than  otherwise.  Yet  it  is  a  Avell-knoAvn  fact,  that  the 
strength  and  tonicity  of  any  tissue,  more  especially  of  muscular 
fiber,  is  increased  in  proportion  to  the  amount  of  resistance 
required  of  it,  and  vice  versa.  Thus,  if,  from  any  cause,  and 
the  most  frequent  is  Avant  of  proper  attention  after  child-bearing, 
the  abdominal  muscles  become  Aveakened,  there  is  much  less 
pressure  exerted  on  the  perineum,  the  nutrition  of  the  perineal 
muscles  is  weakened,  and  after  a  length  of  time,  they  lose  their 
normal  power  of  contraction,  and  the  result  is  a  passive  prolapse 
of  the  uterus.  That  this  is  an  important  cause  of  the  disease,  is 
22 


338  DISEASES     OF     WOMEN. 

well    shown    by    the    benefit    that    is    obtained    from    properly 
constructed   abdominal   supporters,   which,  instead   of  increasing 
the  prolapse,  as  it  might  seem,  by  compressing  the  abdominal  and 
pelvic  contents,  in  a  majority  of  cases  furnishes  great  relief. 

700.  This  lengthy  consideration  of  the  anatomy  and  pathology 
of  the  disease  may  seem  out  of  place,  yet  I  believe  it  will  be 
found    of    more    advantage    to    the    practitioner    than    pages    of 
empirical    treatment.      In    studying    a   disease,  we   wish  first  to 
know  its  pathological  character,  and  the  structures  involved  in  it, 
and  then  the  treatment  becomes  comparatively  easy.     It  certainly 
would  make  a  great  difference  in  the  treatment  of  this  disease, 
whether  we   considered  that  it   arose  from   a  relaxation  of  the 
vagina,  the  perineum  and  its  muscles,  and  the  abdominal  Avails, 
or  whether,  according  to  the  generally  received   opinion,  it  arose 
from  a  relaxation  of  the  uterine  ligaments. 

701.  The   causes   that  produce  this  relaxation,   are:    frequent 
child-bearing,  abortions,  the  too  early  adoption,  or  too  long  con- 
tinuance of  the  erect  posture  after  delivery  or  miscarriage,  before 
the  uterus  and  its  connections  have  recovered  their  normal  size 
and  tone.     Again,  chronic   catarrh  of  the  vagina,  by  weakening 
the  vaginal  walls,  will  also  pre-dispose  the  patient  to  prolapse. 

702.  Another  cause  of  prolapsus,  even  where  the  support  is 
sufficient  to  retain  the  normal-sized  uterus  in  position,  is  to  be 
found  in  the  hypertrophy  and  consequent  increased  weight  of  the 
cervix  uteri,  or  even  the  entire  organ,  the  result  of  inflammation. 
It  may  also  be  caused  from  the  increased  weight  of  the  organ  in 
congestion,   or  from  the  presence   of   fibroid  tumors,   malignant 
growths,  etc.     According  to  Dr.  Bennet,  "  The  partial  prolapsus 
of  the  uterus  is  really  owing,  in  the  immense  majority  of  cases, 
solely  to  increase  in  the  volume  and  weight  of  the  cervix,  and  to 
the   relaxed  state  of  the    vagina,  induced  by  inflammation  and 
distention,  must  soon  become  apparent  to  any  practitioner  who 
gives  himself  the  trouble  accurately  to  ascertain  the  position  of 
the  enlarged  and  inflamed  cervix,  when  a  patient  first  applies  to 
him  for  advice,  and  to  compare  it  with  that  which  it  occupies 
when  the  ulceration  is  healed,  the  hypertrophy  reduced,  and  the 
vagina  restored  to    a  healthy  state  of  contractility.      He  will 


PROLAPSE  OF  THE  UTERUS.  Oo9 

then  almost  invariably  find  the  cervix  two  or  three  inches  higher; 
the  finger  which  at  first  found  the  cervix  low  down,  just  behind 
the  vulva,  being  often  barely  able  to  reach  it." 

703.  Symptom^. — The   symptoms   of  this  affection   vary  much 
according  to  the  degree  of  displacement,  and  the  cause  by  Avhich 
it  was  produced.     Those  produced  by  the  displacement  itself,   are 
principally  mechanical,  arising  from  the  pressure  of  the  prolapsed 
uterus  on  the  adjacent  organs,  and  the  sympathies  existing  between 
the  uterus  and  other  parts  of  the  system. 

704.  In  the  first  decree  of  prolapse,  or  relaxation,  the  s.ymp- 

O  I  «/         1 

toms  are  very  slight,  without  it  arises  from  inflammation  and 
hypertrophy  of  the  cervix,  or  some  other  structural  disease  of  the 
organ, when  the  symptoms  will  be  those  of  the  structural  disease, 
and  not  consequent  on  the  displacement.  In  some  cases,  where 
no  uterine  disease  exists  except  the  displacement,  the  patient 
complains  of  a  dull,  heavy  pain  in  the  small  of  the  back,  and  a 
sensation  of  weight  and  dragging  in  the  pelvis,  and  extending  to 
the  anus  ;  this  becomes  more  painful  by  remaining  long  on  the 
feet,  or  by  too  much  exercise. 

705.  According   to   INI.   Colombat,  most  of   the   symptoms   of 
prolapsus   in  the  second  stage  are   mechanical,  produced  by  the 
pressure  of  the  uterus  upon  the  surrounding  parts,  especially  the 
bladder  and  rectum.     This  is  put  beyond  question,  by  the  fact, 
that  all  the  symptoms  are  diminished  by  rest,  and  particularly  by 
rest  in  the  horizontal   position,  whereas  their  violence  is  greatly 
increased  by  standing  and  walking.     Where  the  displacement  has 
been    gradually    produced,   the    symptoms    attending  it   are  less 
severe  than  when  it  takes  place  suddenly ;  where  it  is  suddenly 
produced,  it    is    frequently   accompanied    with   long,    protracted 
faintings,  violent  floodings,  some  pain  in  the  pelvis,  vomiting,  and 
sometimes  even  an  intense  attack  of  peritonitis.     But  on  the  con- 
trary, where  the  displacement  takes  place   slowly,  these  pheno- 
mena  are   rarely    observed,    because    the    organs    having    slowly 
abandoned  their  natural  situation,  become,  in  a  measure,  accus- 
tomed to  the  unnatural  situation  they  have  assumed. 

706.  In  complete  prolapse,  or  procidentia  uteri,  the  symptoms 
above  named  are  generally  aggravated,  the  pain  in  the  back  is 


340  DISEASES     OF     WOMEX. 

more  severe,  and  accompanied  by  pain  in  the  groins  and  labia,  in 
which  there  is  a  sensation  of  fullness.  The  sensation  of  weight 
and  dragging  down,  "  as  if  (as  the  patients  will  describe  it)  every 
thing  is  dropping  through."  The  patient  can  not  remain  in  the 
erect  posture  for  any  length  of  time,  and  exercise  aggravates  her 
sufferings,  and  she  finds  ease  only  in  the  horizontal  position.  To 
these  symptoms  are  frequently  added  those  of  obstinate  constipa- 
tion, tenesmus,  a  frequent  but  ineffectual  desire  to  evacuate  the 
rectum,  etc.  The  bladder  is  likewise  more  or  less  affected,  the 
patient  having  a  frequent  desire  to  urinate,  or  there  may  be 
entire  inability  to  pass  the  urine,  or  it  may  pass  in  drops,  the 
patient  being  unable  to  retain  it ;  in  some  cases,  the  patient  will 
have  to  lie  down  and  partly  replace  the  uterus  before  the  urine 
can  be  passed. 

707.  The  effect  produced  by  this  displacement  on  the  general 
health  is  very  various.     Some  patients  will  make  no  complaint ; 
their  general  health  being  as  good  as  it  was  before  the  displace- 
ment, even  in  the  worst  form  of  it.    In  others,  the  digestive  organs 
sympathize    with  the  uterine   disease ;    there  is   disorder  of  the 
stomach,  loss  of  appetite,    or    it   may  be    capricious,  dyspepsia, 
distension  of  the  abdomen,  headache,  etc. 

708.  The  menstrual  functions  are  very  rarely  disturbed ;  mens- 
truation occurring  at  the  regular  intervals  and  in  normal  quantity. 
The  reproductive  functions  are  likewise  very  little  disturbed ;  the 
prolapse  of  the  uterus  proving  no  impediment  to  impregnation, 
so  long  as   the  uterus   is  retained  within  the  vagina,  or  can   be 
returned.     Prolapse  of  the  uterus,  in  nearly  every  case,  is  accom- 
panied with  more  or  less    leucorrheal  discharge  ;    this  generally 
arises  from  the  vagina,  without  there  also  exists  inflammation  of 
the  cervix,  when  the  canal  of  the  cervix  will  furnish  a  portion 
of  the  secretion. 

709.  Diagnosis. — No  difficulty  will  be  experienced  in  forming 
a  diagnosis,  if  a  careful  vaginal  examination  be  made.     It  will  be 
recollected  that  in  prolapsus  uteri,  in  every  case,  the  os  uteri  will 
be  the  lowest  portion  of  the  tumor,  when  then  the  os  uteri  presents 
at  the  lowest  portion  of  the  tumor,  it  is  perfectly  conclusive  in  any 
degree  of  displacement.     If  there  should  be  any  doubt  that  it  ia 


PROLAPSE     OF     THE     UTERUS.  341 

the  os,  the  uterine  sound  or  a  small  bougie,  introduced  into  the 
uterus,  will  be  proof  positive.  It  can  never  be  difficult  to 
distinguish  prolapse  of  the  uterus  from  inversion,  as  in  this  latter 
disease  the  os  uteri  will  be  absent,  and  the  mucous  membrane  of 
the  organ,  which  now  forms  its  external  investment,  can  not  be 
mistaken  for  the  smooth,  pink-colored,  and  shining  vagina. 

710.  Treatment. — The  treatment  of  this  disease  presents  two 
indications ;    first,   to  return  the  prolapsed    organ  to  its   natural 
position,  and  second,  to  prevent  a  recurrence  of  the  displacement. 
Though  the  indications  are  very  plain,  there  is  a  great  difference 
in  the  means  recommended  by  authors  to  meet  them.    Among  the 

i/  O 

measures  recommended  may  be  mentioned,  rest  in  the  horizontal 
position  as  long  as  possible,  the  use  of  vaginal  injections  of  the 
vegetable  and  metallic  astringents,  the  use  of  the  pessary,  and  a 
surgical  operation  for  the  contraction  of  the  vagina  denominated 
episorrhaphia. 

711.  Though  rest  in  the  horizontal  position  will  give  tempo- 
rary relief,  yet  it  can    never   effect   a   cure  without  appropriate 
means    to    give    strength  and  tone    to   the  vagina,  the    perineal 
muscles,  etc.    Even  then  it  is  disadvantageous  ;  for  the  structures 
which  support  the  uterus  lose  their  power  when  the  natural  pres- 
sure is  taken  off.      We  might  just  as  well  expect  the  muscles  of 
the  blacksmith's  arm  to  increase  in  size  and  strength  by  keeping 
it  extended  upon  a  splint,  as-  to  expect  the  perineal  structures  to 
regain  their  tone  by  removing  the  tension  upon  them.     This  view 
of  the  subject  is  supported  by  Dr.  Hamilton.    He  says  :  "Although 
the  horizontal  posture  immediately  relieves  the  uneasy  feelings  of 
the  patient,  the  author  (long  ago)  ascertained  that  it  tended  not 
only  to  impair  the  general  health,  but  also  to  aggravate  the  disease, 
by  increasing  the  relaxation  of  the  natural  supports  of  the  womb ;" 
and  daily  experience  has  established  the  truth  of  this  opinion. 

712.  Astringent    injections    have    been    much    used    in    this 
disease,  even  by  those  who    advocate  the  theory  that  prolapsus 
uteri  arises  from  relaxation  of  the  uterine  ligaments.     That  they 
give   temporary  relief,  can  not  be   denied ;    but    that   permanent 
benefit  should  be  derived  from  their  use,  I  think  may  be  doubted. 
Dr.  Hamilton    objects    to    their   use   on   the   following   grounds : 


342  DISEASES    OF   WOMEN. 

"  1st.  On  the  supposition  that  styptic  injections  were  safe,  anrl 
that  they  could  readily  restore  tone  to  the  vagina,  (which  the 
author  concedes  for  the  sake  of  argument,  for  the  contrary  is  his 
sincere  belief),  it  must  be  obvious  that,  if  his  view  of  the  nature 
of  the  disease  be  correct,  no  benefit  could  accrue  from  the 
practice.  Accordingly,  no  practitioner  trusts  to  those  means, 
in  cases  of  any  considerable  degree  of  prolapsus  uteri.  2d.  It  is 
admitted  that,  as  the  irritability  of  the  mucous  membrane  of  the 
vagina  varies  in  different  women,  as  well  as  in  the  same  woman 
at  different  periods  of  time,  the  injection  of  strong  astringents 
may  prove  injurious.  Doubts  are  therefore  entertained  of  the 
safety  of  the  practice,  even  by  those  who  recommend  it.  3d.  The 
author's  experience  has  convinced  him,  that  astringent  injections 
into  the  vagina  are  apt  to  injure  the  uterus  rather  than  the  canal 
into  which  they  are  thrown.  He  can  solemnly  aver,  that  the 
numerous  cases  of  chronic  enlargement  of  the  uterus,  which  have 
fallen  under  his  notice,  by  far  the  greater  number  had  been 
unequivocally  occasioned  by  the  use  of  styptic  injections  per 
vaginam.  4th.  The  immediate  effect  of  such  injections,  in  cases 
of  prolapsus  uteri  of  any  standing — viz.,  the  diminution  or 
suppression  of  leucorrheal  discharge — has  been,  in  many  cases, 
followed  by  distressing  head-aches,  or  obstinate  inflammation  of 
the  eyes,  or  eruptions  on  the  face." 

713.  We  have  a  class  of  agents,  however,  some  of  which  have 
slight  astringent  properties,  against  which  the  above  objections  do 
not  hold  good  ;  they  are  beneficial,  not  on  account  of  their  astrin- 
gency,  but  from  their  stimulant  and  tonic  effect  on  the  vaginal 
canal  and  the  parts  adjacent.  Of  these  agents  we  might  enume- 
rate the  Hydrastis  Canadensis,  Rubus  Villosus,  Statice  Limonum, 
R-hus  Glabrum,  Myrica  Cerifera,  and  others.  The  indications  for 
the  use  of  these  agents  are,  the  existence  of  that  state  of  chronic 
inflammation  of  the  vaginal  mucous  membrane  known  as  vaginal 
catarrh,  or  vaginal  leucorrhea.  This  condition  may  exist  previous 
to,  and  be  one  of  the  producing  causes  of  the  displacement,  or  it 
may  arise  after,  and  be  an  effect  of  it.  The  directions  for  the 
use  of  the  above  agents  in  this  condition,  will  be  found  under  the 
head  of  chronic  vaginitis. 


DROPSY  OF  THE  UTERUS.  343 

714.  The  use  of  pessaries  in  the   treatment  of  displacement  of 
the  uterus   is    of    the   highest  antiquity;   they  were  used  by  the 
Egyptians,   Greeks,  Romans,  and  Arabians,   and,  at   the   present 
time,    they   are    in    general   use   as  a    so-called  remedy   for  this 
affection.     They    are    made    of   gold,    silver,    lead,   wood,    cork, 
sponge,  gum-elastic,  or  of  linen,  in  the  form  of  a  sack,  and  filled 
with  some  medicinal  substance.     In  form  they  are  round  or  oval, 
or  in  the  form  of  a  ring  with  a  central   opening,  or  like  an  hour 
glass,   "  en   bondon,    or   en  bilboquet."     They   all   have   for    their 
object  the  mechanical  support  of  the  uterus,  either  from  below,  as 
in  the  pessary  en  bilboquet,  or  by  dilating  the  vagina  and  making 
pressure  on  the  bladder  and  rectum,  and  being  supported  by  these 
organs,  as  in  the  pessary  en  bondon. 

715.  That  this  method  of   relieving  prolapse  of  the  uterus  is 
merely  palliative,  and  though  in   some  exceptional  cases  success- 
ful, through  an  irritation  or  inflammation  of  the  vagina,  occasioned 
by  their  use,  which  has  caused  contraction  of  that  canal,  yet  that, 
in  the  majority  of  cases,  it  has  aggravated  the  diseased  condition 
of  the   structures   supporting   the   uterus,   I  think   can    be  fully 
proved.*     The  use  of  a  pessary  of  sufficient  size  to  support  the 


*  Dr.  Meigs'  views,  appended  as  a  note  to  his  translation  of  Colombat  on  the 
Diseases  of  Females,  will  be  found  to  be  correct  in  every  particular.  He  says: 

"I  take  advantage  of  the  close  of  this  section  to  make  a  few  remarks  on  the 
subject  of  the  pessary,  and  particularly  on  the  pessary  as  used  in  this  city;  and, 
in  the  first  place,  I  must  express  my  conviction  that  great  abuses  are  to  be  met 
•with  in  the  prescription  and  use  of  this  instrument,  while  a  great  many  persons 
are  restored  to  health,  and  many  preserve  a  tolerable  state  of  health  by  their  use, 
who,  but  for  such  aid,  would  become  irremediably  diseased,  or  pass  a  long  life  of 
suffering.  Many  objections  have  been  cited  in  the  preceding  pages,  by  our  author, 
to  the  use,  or  rather  to  the  abuse  of  this  instrument,  and  the  very  natural  and, 
perhaps,  praiseworthy  opposition  to  their  employment,  arising  from  considerations 
of  a  merely  moral  nature,  ought  to  be  encouraged,  as  a  means  of  preventing  their 
unnecessary  use  as  means  of  treatment  in  cases  not  at  all  calculated  to  be  bene- 
fited by  them.  It  seems  to  me  that,  in  view  of  the  nature  of  the  support  by 
means  of  which  the  womb  retains  its  natural  situation  in  the  pelvis,  every  case 
of  prolapsion  or  procidentia  of  the  womb,  ought  to  be  regarded  as  an  affection  of  the 
vagina,  and  that  the  indication  of  cure  confines  itself  to  the  restoration  of  the 
vagina,  and  not  of  the  womb,  as  the  pathological  object. 

"The  abdominal  cavity  is  terminated  above  by  the  concave  of  the  diaphragm 


344  DISEASES    OF    WOMEN. 

uterus,  will  invariably  increase  the  dilatation  of  the  vagina,  and  the 
lax  condition  of  its  walls,  the  very  thing  we  wish  to  avoid.  As  we 
have  already  seen,  the  vaginal  walls  in  a  normal  condition  are  in 
direct  apposition,  being  compressed  together  by  the  rectum  behind 
and  the  bladder  in  front,  and  any  thing  that  will  cause  a  deviation 
from  this  normal  position,  will  increase  the  existing  debility.  The 
pressure  of  a  pessary  not  only  causes  a  dilatation  of  the  vagina, 
but  it  also  exerts  an  injurious  compression  on  the  bladder  and 
rectum,  these  organs  in  a  normal  condition,  being  only  separated 
by  the  thickness  of  the  vaginal  walls.  It  likewise,  by  taking  off 
the  pressure  of  the  pelvic  and  abdominal  contents  upon  the 


and  inferiorly  by  the  floor  of  the  pelvis,  consisting  of  tissues  of  combined  muscles, 
fasciae,  cellular  tela  and  skin.  In  the  act  of  parturition,  and  in  that  of  defe- 
cation, the  inferior  portion  of  the  abdominal  cavity  is  depressed  by  the  action  of 
the  diaphragm  and  abdominal  muscles,  which  press  the  movable  contents  toward 
the  outlet^  and  depress  it.  In  this  act  the  whole  perineum  descends  more  or  less 
considerably,  and  after  the  completion  of  the  act  returns  to  its  natural  position, 
partly  by  means  of  its  contractility  of  texture,  and  partly  by  the  act  of  the 
levator-ani  muscles — muscles  that,  in  almost  every  instance  of  this  return,  are 
put  into  voluntary  activity. 

"  With  the  progress  of  age,  and  under  the  debilitating  powers  of  disease,  the 
perineal  terminus  of  the  abdominal  cavity  grows  less  and  less  able  to  resist  the 
antagonization  of  the  diaphragm  and  abdominal  muscles ;  so  that,  in  such  circum- 
stances, the  perineum  becomes  relaxed,  and  is  found  to  be  nearly  horizontal  or 
quite  even  with  the  tuber  ischii;  whereas,  in  young  and  healthy  persons  it  is 
drawn  upward  so  as  to  make  a  deep  sulcus  above  the  level  of  those  tuberosities. 

"In  all  persons  possessed  of  very  powerful  levators-ani,  the  extremity  of  the 
rectum  will  be  highly  retracted  within  the  pelvis,  and  retained  there  by  the 
steady  and  normal  tension  of  those  muscles;  but  in  those  in  whom  these  levators 
are  thin  and  weak,  the  anus  is  found  lower  and  on  a  level  with  the  tubera,  or 
even  projecting  below  them.  This  case  may  sometimes  be  detected  in  young 
children  exhausted  with  the  long  tenesmus  of  summer  complaint;  in  adults,  under 
protracted  diarrhea,  dysentery,  and  other  enfeebling  maladies,  as  well  as  in 
•women  whose  constitutions  are  broken  up  by  frequent  parturition. 

u  Now  let  it  be  remembered  that  the  levator-ani  is  a  levator  vaginae,  and,  in 
the  same  sense,  a  levator  uteri ;  and  that  in  all  persons  in  whom  these  muscles 
have  become  extenuated  and  weak,  there  will  be  a  greater  or  less  disposition  to, 
or  actual  falling  of  the  womb;  and  that  such  a  condition  is  incompatible  with 
comfortable  sensations  in  the  muscles  in  question.  Even  the  constrictor  vaginae 
muscle  is,  to  a  certain  degree,  a  part  of  the  muscular  material  in  question,  since 
the  levators  and  sphincters,  both  of  the  anus  and  vagina,  have  their  fibers  more 
or  less  blended,  and  there  is  a  consent  in  their  actions.  The  levators  relax 


DROPSY     OF     THE     UTERUS.  345 

perincal   muscles,  causes  a  loss   of  tone   and  energy  in  these,  the 
true  supports  of  the  pelvic  contents. 

710.  Dr.  Hamilton  urges  the  following  objections  to  the  use  of 
pessaries:  "'  1st.  They  can  only  act  as  palliatives,  whatever  may 
be  the  degree  of  the  disease.  2d.  They  necessarily  keep  up  a 
continued  irritation  in  the  passage,  and  of  course  a  mucous  dis- 
charge from  the  vagina.  3d.  Unless  properly  adapted,  they 
make  injurious  pressure  on  the  contents  of  the  pelvis.  4tli.  If 
not  frequently  taken  out  and  cleaned,  they  become  incrusted  with 
calcareous  matter,  which  proves  highly  irritating.  5th.  They  sub- 
ject the  patient  to  the  charge  of  the  medical  attendant  for  life. 


coincidently  with  the  relaxation  of  the  sphincter  ani,  and  their  contractile  efforts 
absolutely  coincide. 

"  Seeing  now  that  the  uterus  depends  for  its  place  in  the  plane  of  the  pelvic 
cavity,  solely  upon  the  place  of  the  vagina,  and  that  the  latter  is  indissolubly 
connected  with  the  bowel  by  means  of  the  recto-vaginal  septum,  it  appears  clearly 
that  all  cases  of  prolapsion  have  also  a  clear  connection  with  a  certain  morbid 
condition  of  the  levator  muscles.  The  same  thing  happens  in  the  case  of  falling 
of  the  palate  or  uvula,  which  is  clearly  a  muscular  weakness,  arising  from  an 
inflammation,  either  acute  or  chronic,  of  the  substance  of  the  palate  or  uvula. 

"  It  hence  appears,  that  in  cases  of  prolapsus  uteri,  I  suppose,  that  one  great 
object  to  be  held  in  view  is  the  restoration  to  the  levators  of  their  lost  or  dimin- 
ished contractility. 

"Doubtless,  cases  of  prolapsion  are  most  to  be  feared  after  long,  tedious,  or 
instrumental  labors — labors  where,  from  rigidity  or  bad  proportion,  the  child  has 
remained  many  hours  within  the  pelvic  cavity,  jamming  the  muscular  and  other 
tissues  within,  against  the  sides  of  the  ischia,  whose  bony  walls  on  the  one  hand 
contuse  these  muscles,  while  the  head  on  the  other  is  equally  capable  of  affecting 
them  with  contusion. 

"After  such  a  labor,  a  woman  is  very  apt  to  get  up  from  her  lying-in  with 
•weakened  levators,  with  the  rectum  feebly  supported,  and  the  uterus  consequently 
lower  than  it  ought  to  be;  in  fact,  very  few  women  are  to  be  met  with  in  whom, 
after  giving  birth  to  one  or  two  children,  the  womb  is  not  found  very  low  in  the 
pelvis.  If  she  early  becomes  a  widow,  or  at  an  early  age  ceases  to  bear  children, 
the  tension  of  these  tissues  is  at  length  restored  to  the  womb,  and  the  whole 
perineum,  indeed,  rises  again,  until  the  approach  of  age  is  evinced  by  the  last 
and  permanent  fall  of  the  perineum  with  all  the  contents  of  the  pelvis. 

"  Under  this  view,  how  necessary  does  it  seem  that  such  patients  should  avoid 
ail  the  causes  of  tenesmus,  such  as  costiveness  on  the  one  hand,  and  drastic  or 
other  harsh  cathartics  on  the  other,  pessaries  of  a  bad  construction,  or  of  too 
large  a  size,  strangury,  debilitating  discharges  of  leucorrhea,  and,  in  short,  what- 
ever might  serve  to  promote  the  descent  of  the  perineal  texture,  the  descent  of 


346  DISEASES     OF     WOMEN. 

And  lastly.     Cases  from  time  to  time  occur,  where,  from  laceration 
of  the  perineum,  etc.,  no  ordinary  pessary  can  be  retained." 

717.  Having  thus    considered   the  three  most  common  means 
of  treating  this  displacement,  and  seeing  that  these  can  not  be 
depended  on  to  effect  a  radical  cure  of  the  disease,  we  will  now 
consider  those  measures  which  have  for  their  object  the  restora- 
tion of  the  natural  support  of  the  parts. 

718.  Our  first  object  in  a  case  of  this  kind,  is  to  restore  the 
general  health  of  the  patient,  which  is  more  or  less  affected,  and 
thus  indirectly  give  tone  and  vigor  to  the  perinea!  structures.     To 
this  end,  any  dyscrasia  to  which  the  patient  is  subject,  should  be 
corrected,  the  bowels  kept  regular,  and  the  urinary  and  cutaneous 
secretions  kept  free.     The  patient  should  be  placed  upon  the  use 
of   the    vegetable   tonics   and  iron,   and   stimulants   if    they   are 
needed ;  she  should  be  advised  to  take  plenty  of  exercise  in  the 


which  is  incompatible  with  a  due  elevation  of  the  organs  whose  support  in  situ 
naturally  absolutely  depends  upon  them. 

"  I  beg  leave  to  remark  that,  in  pursuance  of  a  plan  of  treatment  by  rest  in  a 
horizontal  posture  very  long  continued,  the  muscular  force  of  the  patient  is  not 
unapt  to  be  exhausted,  and  that  it  is  not  unusual  for  persons  subjected  to  such 
treatment,  to  rise  from  a  confinement  to  the  bed  of  several  months  duration,  not 
at  all  amended  in  health,  and,  consequently,  greatly  disappointed,  if  not  injured 
by  the  treatment.  In  such  patients,  a  method  calculated  to  invigorate  and 
enhance  the  muscular  energies  would  be  far  more  likely  to  produce  a  cure  which 
would  coincide  with  a  rise  or  elevation  of  the  perineum.  Hence,  I  have,  in  many 
instances,  found  my  patients  to  recover  perfectly,  when  I  have  counseled  them  to 
take  exercise,  to  be  much  in  the  air  and  light,  to  live  upon  a  nutritious  diet,  tc 
take  wine  and  malt  liquor,  and  to  disregard,  as  far  as  possible,  the  painful  or 
annoying  sensations  proceeding  from  the  prolapsed  state  of  the  womb;  assuring 
them  that,  probably,  in  proportion  as  their  general  health  should  improve,  so 
would  the  local  disorders,  under  which  they  suffered,  gradually  lessen  and  finally 
disappear.  I  have  seen  a  lady  this  day,  who,  at  the  age  of  forty-nine  years, 
informs  me  that  she  has  scarcely  been  a  day  or  night  without  a  pessary  for  four- 
teen years  past,  an  instrument  for  which  she  has  not  the  least  occasion,  and 
perhaps  never  has  had. 

"  In  making  these  remarks,  I  desire  to  apply  them  to  cases  where  the  use  of 
the  pessary  is  a  question  of  doubt,  for,  beyond  dispute,  there  are  many  women 
who  can  enjoy  neither  comfort  nor  health  without  the  aid  of  these  remedies,. 
which,  as  our  author  states,  are  sanctioned  by  the  common  consent  of  the  profes-- 
sion  for  ages  past." 


DROPSY     OF     Till-]     UTERUS.  34  / 

open  air,  and  to  live  upon  a  nutritious  but  digestible  diet.  Strict 
attention  should  be  paid  to  the  state  of  the  skin,  using  the  bath 
at  least  once  a  day,  and  accompanying  it  with  considerable  fric- 
tion. As  the  general  health  improves,  in  a  majority  of  cases,  an 
equal  improvement  will  be  observed  in  the  local  disease.  Dr. 
Meigs,  in  reference  to  constitutional  treatment,  remarks :  "  I  have, 
in  many  instances,  found  my  patients  to  recover  perfectly,  when  I 
have  counseled  them  to  take  exercise,  to  be  much  in  the  air  and 
light,  to  live  upon  a  nutritious  diet,  to  take  wine  and  malt  liquor, 
and  to  disregard  as  far  as  possible,  the  painful  or  annoying  sensa- 
tions proceeding  from  the  prolapsed  state  of  the  womb ;  assuring 
them,  that  probably  in  proportion  as  their  general  health  improved, 
so  would  the  local  disorders  under  which  they  suffered,  gradually 
lessen  and  disappear." 

719.  In  regard  to  local  measures,  our  first  attention  should  be 
directed  to  the  removal  of  any  disease   of  the  vagina  or  uterus 
that  may  exist.     Thus,  if  there  be  a  chronic  inflammation  of  the 
mucous   membrane  of  the  vagina,  it  should  be  removed  in  the 
manner  already  described,  when  treating  of  that  disease.     In  the 
first  degree  of  prolapse,  many  cases  will   present  themselves  in 
which  the  displacement  was  caused  by  hypertrophy  of  the  cervix; 
the  removal  of  this  diseased  condition  will  be  followed  by  a  cure 
of  the  displacement.     After  the  removal  of  these  diseases,  or  if 
the  prolapse  existed  without  them,  the  local  applications  should 
entirely  consist  of  cold  water,  applied  to  the  lower  portion  of  the 
abdomen  and  pelvis  with  the  hand,  and  used  as  a  vaginal  injec- 
tion, with  a  pump-syringe. 

720.  To  increase  the  tone  and  strength  of  the  abdominal  and 
perineal  muscles,  they  should  be  exercised  by  compressing  and 
kneading   them   with   the  hand.     Having  reduced  the  uterus  as 
much    as    possible,    the   patient  lying    in    a  horizontal    position, 
the    nurse    should    be    directed    to    manipulate    or    knead    the 
muscles  of  the  perineum  and  abdomen   with  the  hand,  and  this 
should  be  repeated  once  or  twice  a  day.     This  exercise  of  the 
muscles  I  have  found  of  greater  benefit  than  any  other  measure, 
the  condition  of  the   patient  being  sensibly  improved  by  it  in  a 
few  days. 


DISEASES      OF     TTOMEX. 

721.  Dr.  Keith  informs  me  that  he  and  others  have  used  the 
galvanic  battery  in  these  cases  with  marked  advantage,  in  fact,  he 
considers  it  much   preferable  to   any  other  mode   of  treatment. 
He  applies  the  positive  pole  of  the  battery  to  the  lumbar  region 
of  the  spinal  cord,  the  negative  pole  being  introduced  into  the 
vagina.      Under  its  influence   he  has  observed  the  vagina,  which 
was   so   lax    as    to    permit   the   uterus    to    pass    down  with   very 
little    resistance,    become    so    contracted,    that    the    uterus    was 
retained    in  its  normal  position,  though  the  patient  was  told  to 
run   up    and   down   stairs,  jump,   cough,   etc.      He   has   likewise 
noticed,  that  by  taking  the  negative  pole  in  one  hand,  and  intro- 
ducing the  index-finger  of  the  other  to  the  os  uteri,  the  current 
passing  through  him,  that  the  uterus  would  be  elevated  and  drawn 
away  from  the  finger.     He  further  states,  that  the  benefit  derived 
in  this  manner  is  permanent,  the  muscles  being  stimulated  and 
invigorated  by  each  application,  will  in  a  short  time  be  able  to 
afford  a  proper  degree  of  support. 

722.  The  reduction  of  the   displaced  uterus  is  generally  very 
easy,  in  the  first  or  second  stages,  when  unaccompanied  with  any 
complications.     The  patient  lying  in  a  horizontal  position,  with 
her  hips  elevated,  and  the  thighs  flexed  upon   the  abdomen,  the 
physician,  by  the   introduction  of  one  or   two  fingers  to  the  os 
uteri,  can  readily  replace  it ;  in  fact,  in  many  cases  it  will  itself 
assume  its  natural  position. 

723.  In  complete  prolapsus  the  reduction  is  sometimes  attended 
with  much  difficulty.     In  this  case,  according  to  M.  Colombat,  it 
is  proper,  before  proceeding  to  the  reposition,  that  the  patient 
should  empty  the  bladder  and  rectum,  either  spontaneously  or  by 
means  of  the   catheter   and    a   common    enema.     Provided    the 
uterine  tiynor,  as  frequently  happens,  should  be  found  painful  and 
sore  from  the  action  of  the  air,  the  urine,  or  the  friction  of  the 
clothing,  emollient  poultices  ought  to  be  applied  to  it,  and  the 
swelling  should  be  reduced  by  general  remedies,  such  as  fomenta- 
tions, baths,  diluent  drinks,  laxatives,  etc.     After  the  parts  have 
been  brought  into  a  condition  more  favorable  for  the  reposition, 
the  woman  should  be    directed  to  lie  down   in    a  position    more 
inclined  even  than  that  recommended  in  incomplete  prolapsus ; 


DROPSY"     OF     THE     UTERUS 


the  physician,  after  anointing  his  fingers,  as  well  as  the  tumor 
itself,  with  cerate  or  oil,  should  seize  it  with  his  right  hand,  and, 
giving  a  few  rotary  movements,  in  a  gentle  manner,  and  then 
elevating  and  depressing  it  by  turns,  should  press  it  backward 
into  the  pelvis,  following  the  direction  of  the  axis  of  the  inferior 
strait,  meanwhile  using  the  fingers  of  the  other  hand  at  the  labia, 
to  facilitate  the  return  of  the  womb  into  the  body. 

724.  To  support  the  uterus  during  the  treatment  for  the  radical 
cure  of  the  disease,  a  perineal  supporter  (Fig.  34-5,)  should  be 
constantly  worn  by  the  patient  through  the  day,  when  she  is  in  an 
upright  position,  and  taking  exercise.  This  supporter  consists  of 
a  well-fitted  abdominal  bandage  or  jacket,  furnished  with  whale- 
bones, to  keep  it  from  wrinkling,  and  made  so  that  it  will  give  a 
constant  and  steady  support  to  the  lower  and  anterior  portion  of 
the  abdomen  ;  from  this  jacket  extends  two  stout  and  inelastic 
bands,  which  pass  between  the  thighs,  and  button  or  buckle  on 
the  opposite  part  of  the  bandage ;  immediately  under  the  peri- 
neum, where  these  straps  cross,  a  perineal  pad  is  attached,  which 
presses  upward  against  the  perineum,  and  gives  the  requisite 


FIG.  34. 


PERINEAL  SUPPORTERS. 


degree  of  support.  This  perineal  supporter  has  been  used  by  Dr. 
Brown  and  others,  and  is  preferred  to  any  other  means  of  sup- 
port. In  my  practice  I  use  it  altogether,  and  prefer  it  to  any  and 


350  DISEASES     OF     WOMEN. 

all  contrivances    which    have    been    recommended  for    the    same 
purpose. 

725.  In  those  cases  where  the  prolapsus  arises  from  rupture  of 
the  perineum,  the  operation  recommended  for  this  difficulty  should 
t>e  resorted    to,  and  with    the    restoration    of   the  perineum    the 
uterus  will  assume  its  normal  position. 

726.  In  cases  in  which  the  perineum  is  thin  and  much  weak- 
ened,   its    restoration    to    a    normal   thickness    and    strength,  by 
a  surgical   operation,   will   effectually   remove    the    displacement. 
These  cases  are  the  hardest  to  cure;  in  fact,  where  the  perineum 
is  greatly  weakened,  as  it  is  in  some  rare  instances,  this  operation 
is  the  only  sure  means  of  relief.     The  principle  of  the   operation 
is  the  same  as   in   prolapsus  vagina,  to  increase   the  thickness  of 
the    perineum,    and    contract    the    size    of   the  vagina.      As    the 
operation  is  nearly  the  same  as  for  vaginal  prolapse,  the  reader 
is  referred  to  that  for  the  description. 

RETROVERSIOX  OF  THE  UTERUS. 

727.  This  displacement,   though  not   of   such   common  occur- 
rence as  prolapsus  uteri,  is  still  frequently  met  with,  both  in  the 
pregnant  and  in  the  non-pregnant  female.     It  consists  in  a  dis- 
placement of  the  fundus  uteri  backward,  the  cervix  being  thrown 
forward  against  the  bladder,  the  entire  organ  assuming,  more  or 
less,  a  transverse  position  in  the  pelvis.     It  will  be  recollected, 
that  in  its  normal  condition  the  uterus  corresponds  in  direction 
with  the  axis  of  the  superior  strait,  or  a  line  drawn  from  the  apex 
of  the   coccyx    to    the   umbilicus ;   it   is    not,  therefore,  situated 
perpendicularly  in  the  axis  of  the  body,  but  is  normally  ante- 
verted.     The  vagina,  on  the  contrary,  is  situated  in  the  direction 
of  the  axis  of  the  inferior  strait  or  outlet  of  the  pelvis,  and,  con- 
sequently, the    union   of   the   two    forms   an  obtuse  angle.     The 
uterus  is  said  to  be  retroverted   when  its   direction   corresponds 
with  the  direction  of  the  vagina,  or  when  the  angle  formed  by  the 
two  is  posterior  instead  of  anterior,  the  displacement  varying  in 
degree  from  the  slight  form  first  spoken  of,  to  that  in  which  the 
organ  assumes  a  transverse  position  in  the  pelvis,  or  in  some  rare 
cases,  where  the  fundus  descend  to  a  lower  level  than  the  cervix. 


KETKOVERSION  OF  THE  UTERUS.        351 

728.  Retroflexion  is  but  another  form  of  the  same  disease,  and 
practically  considered,  it  does  not  need  a  separate  consideration. 
In  this  form  of  the  displacement  the  uterus  is  bent  upon  itself. 


FIG.  86. — RETROVERSION  OF  THE  UTERUS. 

like  a  retort,  the  fundus  being  thrown  backward  against  the 
rectum,  the  cervix  retaining  its  natural  position  in  the  pelvis.  In 
regard  to  this  displacement,  Dr.  Bennet  says  :  "  If  the  neck  of 
the  uterus  be  healthy  and  soft,  the  body  of  the  uterus,  in  falling, 
does  not  alter  the  position  of  the  cervix,  and  a  bend  or  angle 
takes  place  between  the  two,  the  concavity  of  which  is  backward 
and  downward.  On  the  contrary,  if  the  cervix  is  enlarged  and 
indurated,  and  the  induration  extends  into  the  body  of  the  uterus, 
the  cervix  is  thrown  up  toward  the  symphysis  pubis,  and  no 
curvature  is  observed."  Though  this  difference  is  found  to  exist 


352  DISEASES     OF     WOMEX. 

in  practice,  yet  it  makes  little  or  no  difference  in  the  symptoms 
developed  by  the  disease,  nor  in  the  measures  adopted  for  its 
relief;  the  distinction,  therefore,  is  practically  useless. 

729.  Causes. — The  proximate  causes  of  this  displacement  are, 
a  laxity  and  weakness  of  the  uterine   supports,  or  an  increased 
weight  of  the  fundus,  posterior  wall,  or  even  of  the  entire  uterus, 
or  both.     Thus,  frequent  child-bearing,  abortions,  chronic  inflam- 
mation of  the  genital  mucous  membrane,  etc.,  will  give  rise  to 
laxity  of  the  tissues,  while    inflammation,  by  producing  hyper- 
trophy,   congestion,    fibrous    tumors,    etc.,    gives    the    increased 
weight  to  the  organ.     In  the  early  period  of  pregnancy,  the  most 
frequent  cause  of  retroversion  is  a  long-continued  distention   of 
the  bladder,  Avhich  either  gradually,  or  under  the  influence  of  a 
sudden  shock  or  impulse,  as  by  a  fall,   coughing,  vomiting,  etc., 
pushes  the  uterus  downward  and  backward  into  the  hollow  of  the 
sacrum. 

730.  Symptoms. — In  some  cases  of  retroversion   of  the  unim- 
pregnated  uterus,   says  Dr.   Simpson,  more  especially  when  the 
displacement  is  chronic,  and  the   pelvis  large,  as  in  some  other 
forms  of  uterine  disease  and  of  pregnancy,  few   or  no  marked 
functional  or  sympathetic  symptoms,  either  local  or  general,  are 
present ;    while,    in    other    instances,    the    attendant    functional 
derangements  and  irritations  are  excessively  severe  and  distress- 
ing.    And  in  this,  as  in  other  uterine  affections,  between  these 
two  extremes  we  may  meet  with  every  shade  of  difference. 

731.  "In   retroversion,    as    in    other    morbid    conditions    and 
diseases  of  the  unimpregnated  uterus,  the  accompanying  sympa- 
thetic derangements  or  symptoms  are,  when  they  are  well  marked, 
more  or  less  perfect  imitations  of  the  secondary  phenomena  of 
pregnancy.     Dyspeptic  and  hysterical  symptoms  are  sometimes 
present,  with  local  neuralgic  pains  in  the  mammae,  in  some  por- 
tions of  the  vertebral  column,  or,  what  is  still  more  frequent,  in  the 
parieties  of  the  abdomen  or  chest,  and,  more  especially,  in  a  limited 
spot  beneath  the  left  mamma.     The  displaced  position  of  the  uterus 
often  gives  rise  to  mechanical  irritations  and   symptoms  of  the 
same  kind  as  if  the  organ  was  morbidly  enlarged.     Constipation 
and   impeded   defecation   are   frequent   results,  partly  from  the 


RETROVERSION  OF  THE  UTERUS.        GOO 

fundus  of  tlie  displaced  uterus  physically  compressing  the  caliber 
of  the  rectum,  and  partly  from  its  producing  a  functional  inability 
to  expel  the  feculent  contents  of  the  bowel  through  the  lowest 
part  of  the  canal.  Occasionally  the  bowel  is  irritated,  and  there 
are  discharged  from  it,  from  time  to  time,  quantities  of  mucous 
or  fibrinous-like  effusions.  The  bladder  frequently  suffers  from 
dysuria  or  retention,  and,  much  more  rarely,  I  have  seen  a  degree 
of  incontinence,  especially  where  the  urine  has  become  phos- 
phatic,  from  the  want  of  power,  in  some  cases,  of  completely 
emptying  the  bladder.  Symptoms  of  weight,  tension,  and  bearing 
down  in  the  regions  of  the  uterus  and  rectum,  with  dragging 
at  the  loins  and  in  the  region  of  the  uterine  ligaments,  are  very 
common.  Pains  often  stretch  down  one  or  both  of  the  lower 
extremities.  Occasionally  there  is  an  inability  to  bear  carriage- 
exercise,  and  walking  and  standing  speedily  produce  fatigue.  In 
a  few  cases  I  have  known  the  patients  to  find  themselves  forced 
to  remain  almost  constantly  in  the  horizontal  position,  from 
the  intense  and  overpowering  feeling  of  pressure  and  malaise 
which  the  erect  posture  always  brought  on,  and  the  power  of 
standing  and  progression  restored  by  the  spontaneous  or  artificial 
reposition  of  the  uterus.  In  general,  all  the  symptoms,  local  and 
constitutional,  which  I  have  alluded  to,  are  aggravated,  more  or 
less,  by  exercise  in  the  erect  position ;  and  they  are  more  particu- 
larly liable  to  be  increased  in  their  intensity  when  the  wterus 
becomes  periodically  congested  and  heavier,  at  the  recurrence  of 
each  menstrual  period." 

732.  The  menstrual  function,  in  some  cases,  is  not  altered  at 
all,  continuing  regular  both  as  to  time,  duration,  and  quantity, 
but  in  other  cases  it  may  be  affected  most  oppositely  and  variously. 
Sometimes  the  secretion  is  suppressed,  at  others  there  is  dys- 
menorrhea,  and  at  others  menorrhagia.  In  some  cases  the  natural 
mucous  secretion  is  not  increased,  but  generally  there  is  a  degree 
of  irritation  or  sub-acute  inflammation,  which  gives  rise  to  a  more 
or  less  abundant  leucorrheal  discharge.  It  is  said  that  when 
a  female  with  a  retroverted  uterus  becomes  pregnant,  abortion 
is  apt  to  take  place.  Many  cases,  however,  are  reported,  in 

•which  utero-gestation  went   on  to  full  term,  the  position  of  the 
23 


354  DISEASES     OF      TTOMEN. 

uterus  becoming  spontaneously  rectified  by  the  consequent 
enlargement  of  the  uterus  ;  again,  some  rare  instances  have  been 
observed,  when  the  occurrence  of  impregnation  increased  the 
displacement.  Very  often  the  existence  of  this  displacement  is 
a  cause  of  sterility,  conception  having  taken  place  when  the 
displacement  was  rectified. 

733.  When  the  impregnated  uterus  is  retroverted,  the  displace- 
ment  always   occurs   while    the   organ  still    remains    within   the 
cavity  of  the  pelvis,  or  before  the  eighteenth  week.    It  is  generally 
not   indicated   by   any  marked   change   in   the   condition   of   the 
patient,  and    she    generally  remains    ignorant    of  her    condition 
until  an  attempt  is  made  to  relieve  the  bladder.     On  attempting 
to  pass  the  urine,  a  stoppage  will  be  observed  in  it,  and  sometimes 
even  the  most   straining    efforts   are    inffectual  in  emptying  the 
bladder  in  the  least.     "  I  wish  it  to  be  understood,  however,"  says 
Dr.  Blundell,  "and  it  is  very  important  that  this  should  be  known, 
that,  in  the  retroversion  of  pregnancy,  you  have  not  always,  nor, 
I  think,   generally,   the  complete    retentions  of  urine;  for,   often 
when  the  uterus  is  retroverted,  the  retention  is  partial.     Day  after 
day  the  fluid  is  sparingly  emitted,  but  never  in  such  quantity  as 
to  empty  the  bladder  completely,  till  by  and  by  the  secretions 
begin  to  steal  away  involuntarily,  or  she  may  have  strong  efforts 
to  pass  the  urine,  even  against  her  will,  and  with  every  effort  a 
small  gush  only  may  be  produced,  or  there  may  be  a  continual 
dripping ;  and  yet,  notwithstanding  all  this,  an  accumulation  of 
water  may  go  on  very  gradually  increasing,  so  that  several  pints, 
nay  several  quarts,  may  be  gradually  accumulated."    The  pressure 
exerted  by  the  fundus  of  the  organ  upon  the  rectum,  gives  rise  to 
a  constant  desire  for  defecation,  even  when  the  bowels  are  empty, 
and  to  great  difficulty  in  evacuating  them. 

734.  Should  these  symptoms  pass  unrelieved,  says  Dr.  Tyler 
Smith,   the   bladder   becomes    enormously   distended,   and   it   is 
sometimes  ruptured  mechanically,  or  its  coats  inflame  and  ulcerate, 
allowing  the  urine  to  escape  into  the  peritoneal  cavity,  and  the 
patient   sinks  or   dies   of  peritonitis.     If  the  uterus  can  not  be 
replaced,  and  the  water  is  occasionally  and  with  difficulty  drawn 
off,  the  bladder  gradually  relaxes  and  elongates,  and  its  mucous 


RET110VKKSIOX     OF     THE     UTERUS.  355 

membrane  becomes  diseased ;  muco- purulent,  ammoniacal,  and 
bloody  urine  is  passed,  and  the  kidneys  may  become  diseased,  by 
the  effects  of  the  backward  pressure  of  the  urine.  The  structures 
between  the  bladder  and  the  uterus  may  become  inflamed,  and  the 
patient  be  destroyed  by  irritative  fever.  In  some  instances  all 
these  mischiefs  are  averted  or  modified  by  the  occurrence  of 
spontaneous  abortion.  In  others,  the  displacement  continues  to 
the  fifth  or  sixth  month,  without  destroying  the  patient,  and  it  has 
been  known  to  go  on  to  the  full  term  without  causing  a  fatal  result. 

735.  Diagnosis. — The  general  symptoms  already  named,  though 
they  point  to  the  uterus  as  the  seat  of  the  disease,  arc  not  sufficient 
to  enable  us  to  determine  its  character,  and  here,  as  in  most  other 
uterine  diseases,  our  main  dependence  is  placed  on  the  results  of  a 
physical  examination. 

736.  By  making  an  examination  per  vaginam  Ave  will  feel  a 
solid    tumor    at    the    posterior   part    of   the   vagina,   smooth  and 
roundish  on  its  surface,  and  more  or  less  sensitive  to  pressure. 
Anterior  to  this  tumor  may  be  felt  the  cervix  uteri,  either  thrown 
forward  and  upward  as  in  retroversion,  or  maintaining  its  usual 
position  as  in  retroflexion.     By  passing  the  finger  backward  along 
the  cervix,  the  connection  between  it  and  the  posterior  projection 
may  in  general  be  easily  made  out.     When  the  displacement  is 
recent,  and  the  uterus  not  enlarged,  the  diagnosis  may  often  be 
greatly  assisted  by  moving  the  uterus,  elevating  its  fundus  by  a 
finger  introduced  into  the  rectum,  and  drawing  the  cervix  down- 
ward, by  a  finger  or  some  suitable  instrument  introduced  into  the 
vagina;    in  this  manner  the  connection   between   the  cervix  and 
the  posterior  projection  may  be  very  easily  determined. 

737.  The  presence  of  the  symptoms  named,  and  the  results  of 
a    tactile    examination,    will    always    be    sufficient    to    detect  the 
displacement  in  the  impregnated    uterus.     But  we  have  a  more 
certain  means  of  diagnosis  in  retroversion  of  the  unimpregnated 
uterus  by  means   of  the  uterine  sound.     In  the  natural  position 
of  the  organ,  the   uterine   sound   is   readily  introduced   with  its 
concavity  directed  forward,  the    point   of   the    instrument   being 
directed  toward    the    umbilicus ;    but,  in    this    displacement,  the 
instrument  can  not  be  introduced  in  that  manner,  as  it  is  resisted 


DISEASES     OF     WOMEN. 

by  the  changed  position  of  the  organ.  By  turning  the  concavity 
of  the  instrument  backward,  hoAvever,  so  that  its  point  will  be 
directed  toward  the  hollow  of  the  sacrum,  it  will  readily  pass. 
This  changed  position  of  the  direction  of  the  uterine  cavity  is 
ositive  evidence  of  the  character  of  the  displacement.  But  we 
may  make  the  examination  still  more  complete  and  accurate,  by 
ascertaining,  by  a  vaginal  or  rectal  examination,  that  the  point  of 
the  bougie  is  lodged  in  the  center  of  the  tumor ;  showing  that 
it  is  the  displaced  fundus,  and  after  this,  by  gently  turning  the 
instrument  round  so  that  its  concavity  will  look  toward  the 
symphisis  pubis,  the  uterus  will  be  replaced,  and  the  posterior 
tumor  can  no  longer  be  felt. 

738.  Treatment. — The  replacement  of  the  uterus,  is  obviously 
the  first  thing  to  be  accomplished  in  all  cases,  both  in  the  pregnant 
and  in   the    non-pregnant  female.      As  the    means  employed  to 
eifect  this,   however,   differ    in   the    two    cases,   we    will    have  to 
consider  them  separately. 

739.  In   retroversion    of  the  unimpregnated   uterus,  there    is 
very  frequently  a    chronic    inflammation,   or    congestion    of   the 
organ,  which  perhaps  has  been  the  cause  of  the  displacement.    This 
as  well  as  any  other  disease  of  the  uterus  predisposing  to  displace- 
ment, must  be  subdued  before  the  organ  will  retain  its  position 
when  replaced.     A  very  good  means  of  replacing  the  organ  is  to 
introduce   one  or  two  fingers  into  the  vagina,  and  pass  them  up 
between  the  cervix  uteri  and  the  rectum,  pushing  up  the  posterior 
vaginal  wall,  and  thus    elevate  the  fundus  of  the   organ,  at  the 
same  time  the  cervix  may  be  drawn  down  by  a  small  instrument 
made  like  one  blade  of  the  forceps,  or   any  thing  else   that  will 
answer  the  purpose.     Another,  and  perhaps  the  best  means  of 
replacing  the  uterus,  is  by  means  of  the  uterine  sound.     Having 
introduced  the  sound  into  the  cavity  of  the  uterus,  if  it  is  gently 
turned  so  that  the  concavity  of  the  instrument  will  look  toward 
the  symphysis  pubis,  the  retroverted  organ  will  be  carried  into  its 
natural  position  by  the  changed  position  of  the  point  of  the  instru- 
ment.    This  use  of  the  uterine  sound  generally  occasions  no  pain, 
if  care  be  used ;  but  if  handled  roughly,  much  pain  and  mischief 
may  be  the  result. 


RET  110  VERSION     OF     THE     UTERUS.  357 

739.  Before  the  replacement  is  effected.,  the  bladder  and  rectum 
should  be  emptied,  and  after  the  replacement  it  is  of  the  utmost 
importance   that   the   urine   should    be   frequently   passed,   never 
allowing  the  bladder  to  become  in  the  least  distended.      This  part 
of  the  treatment  is  of  the  greatest  importance,  for  if  the  bladder 
is  allowed  to  become  distended,  it  will  almost  invariably  reproduce 
prolapse. 

740.  Several    mechanical    contrivances    have    been    used    and 
recommended  to  the  profession  to  retain  the  uterus  in  its  position. 
To  these  instruments,  hoAvever,  the  same  objections  hold  good  that 
were  urged  against  the  use  of  pessaries  in  prolapsus  uteri,  with 
but  one  exception,  Dr.  Simpson's-intra-uterine  pessary.     This  last 
instrument  supports  the  uterus  by  a  stem,  which  passes  into  the 
uterine  cavity,  the  cervix  resting  upon  a  bulb  attached  to  the  stem, 
the  entire  instrument  being  supported  from  below.     Dr.  Simpson 
says,  that  in  his  practice  but  very  little  irritation  has  followed 
their  use,  and  in  no  case  have  they  produced  any  serious  results. 
But  from  the  known  sensibility  of  the  mucous  membrane  lining 
the  cavity  of  the  uterus,  we  should  suppose  that  this  intra-uterine 
stem  would  not  be  so  readily  tolerated.     Dr.  Ashwell  mentions 
some  cases  in  which  great   suffering  resulted  from  its  use,  and 
Dr.  Oldham  mentions  others  where  death  was  the  consequence. 
Dr.  Churchill  states  that  two  cases  have  been  mentioned  to  him, 
in  which  the  instrument  was  introduced,  but  it  occasioned  such 
agony,  that  it  had  to  be  withdrawn  in  both,  within  twenty-four 
hours.     "  Upon   the   whole,  therefore,   I   should   feel  great  hesi- 
tation   in    recommending   such   an  instrument,  although  it  must 
be    admitted    that    some    contrivance'  for    this    purpose    is    very 
desirable.     If  it  be  used,  the  patient  should  be  kept  very  quiet, 
very  carefully  watched,  and  the  instrument  removed  if  it  occasion 
any  pain." 

741.  There  is  no  doubt  in  my  mind,  but  what  if  the  inflamma- 
tion and   enlargement   or  the   congestion  of  the  uterus  be   first 
removed,  and  the  measures  recommended  in  prolapsus  uteri,  for 
the  restoration  of  the  general  health,  and  the  tone  and  strength 
of  the  perineal  structures  be  followed,  that  there  never  will  be 
any  necessity  for  direct  mechanical  support,  "the  perineal  sup- 


358 


DISEASES    OF 


porter  being    all    that   is    required,"   and   this    only   during    the 
general  treatment. 

742.  Dr.  Meigs  considers  that  in  most  of  the  instances  of  retro- 
version  in  the  early  months  of  pregnancy,  the  displacement  is 
attributable  to  a  distended  state  of  the  bladder,  he  says :  "  A 
female  riding  in  a  carriage,  or  placed  in  such  a  situation  that  she 
can  not  withdraw  from  the  company  without  being  suspected  of  a 
desire  to  urinate,  will  allow  the  bladder  to  fill  almost  to  bursting : 
and  if  she  be  pregnant  about  three  months,  she  will  scarcely  fail 
to  have  retroversion  of  the  womb.  When  at  last  she  obtains  an 
opportunity  to  evacuate  the  bladder,  she  finds  she  has  a  partial  or 
total  suppression  of  urine." 


FIG.  37. — AIR  PESSARY  OF  M.  GARIEL. 

743.  In  regard  to  the  treatment  of  these  cases,  he 
"  Having  succeeded  in  drawing  off  the  water,  the  patient,  if  neces- 
sary, should  have  a  copious  enema,  in  order  to  unload  the  rectum, 
which,  if  replete  with  fecal  matters,  might  offer  considerable 
obstacles  to  the  success  of  our  attempt.  In  the  next  place,  we 
ought  to  endeavor  to  raise  the  fundus — the  patient  lying  on  her 
left  side — by  pressing  the  bas-fond  of  the  womb,  which  can  be  felt 


RETROVERSION     OF     THE     UTERUS. 

through  the  hinder  surface  of  the  v.igiua  upward,  with  the  fingers, 
so  as  to  lift  the  whole  mass  in  a  direction  parallel  with  the  axis  of 


FIG.  38. 

the  brim.  The  cervix  uteri  is  tied  to  the  more  anterior  parts  of 
the  pelvis  by  the  vagina  and  the  vagino-vesical  septum,  so  that  if 
we  carry  the  mass  considerably  upward,  it  must  be  by  tilting  the 
fundus  in  that  direction.  Attempts  of  this  kind  will  not  always 
succeed.  Where  they  fail  a  finger  may  be  passed  into  the  rectum, 
the  fore-finger  of  the  left  hand,  if  the  woman  is  on  her  left  side, 
and  of  the  right  hand,  if  she  be  upon  her  back.  Before  the  finger 
has  passed  very  far,  it  meets  with  the  fundus  uteri,  which  presses 
upon  the  canal  of  the  intestine ;  in  this  situation  we  have  far  more 
power  to  move  the  womb  than  when  the  effort  is  made  only  from 
the  vagina.  Pushing  gently  and  steadily  upward,  we  find  the 
mass  gradually  to  recede,  until  at  length  the  fundus,  liberated 
from  its  restraint,  suddenly  emerges,  with  a  sort  of  jerk,  from 
under  the  promintory,  from  which  instant  the  woman  is  cured." 

744.  Sometimes  much  difficulty  will  be  experienced  in  intro- 
ducing the  catheter,  often  indeed  the  common  female  catheter 
can  not  be  used;  in  this  case  an  elastic  male  catheter  should  be 
used,  and  the  uterus  may  be  pressed  backward,  so  as  to  liberate 
the  urethra  until  the  catheter  is  passed. 


SCO  DISEASES     OF     WOMEX. 

745.  If  the  means  above  spoken  of  should  fail  to  replace  the 
uterus,  we  may  resort  to  the  use  of  the  instruments  of  M.  Gariel, 
or  of  Dr.  Henry  Bond  of  Philadelphia.     "M.  Gariel's  instrument 
consists  of  a  dilatable  air  pessary,  terminating  in  a  tube,  and  an 
air  reservoir,  with  small  taps  affixed  to  each.     After  immersion  in 
warm  water,   the   collapsed    pessary  is    passed   into  the   rectum, 
behind   the   uterus,   by  means  of  a  probe.     The  air  reservoir  is 
then  fitted  to  the  tube  of  the  pessary,  the  taps  are  opened,  and, 
by  the  pressure  of  the  hand,  the  air  contained  in  the  reservoir  is 
transferred  to   the  pessary,  so  as  to  lift  the  uterus   out   of  the 
hollow  of  the  sacrum." 

746.  Dr.   Bond's    instrument,    as    described   by    Dr.    Meigs, 
"  consists  of  two  arcs  of  circles  of  different  radii ;  the  inner  one 
is  terminated  by  a  small  oval  piece  of  ivory  ;  the  outer  terminates 
in  a  small  ivory  ball.     The  exterior  arc  is  formed  at  its  lower 
extremity  into  a  plate-piece,  in  which  is  a  mortise  ;  to  the  end  of 
this  plate-piece  is  attached  an  ivory  handle,  by  which  it  may  be 
conveniently  held.     The  inner  or  smaller  piece  is  attached  to  a 
sliding-piece,  also  mortised,  and  overlapping  by  its  edges  the  mor- 
tised plate-piece,  and  secured  by  a 
clamp  or  pinch  traversing  the  mor- 
tises,  and  fastened  or  loosened  by 
turning   the   thumb-piece.      If    the 
thumb-piece  be  unscrewed,  the  clamp 
may  be  turned  lengthwise,  and  the 
arcs  are  then  easily  separated.     In 
order  to  use  the  instrument,  the  arcs 
should  first  be  separated,   and   the 
ivory-ball  on  the  largest  arc  intro- 
duced into  the  rectum,  while  the  oval 
one  on   the  smaller  arc  should   be 
introduced  into  the  vagina.    By  slid- 
ing the  smaller  arc  upward,   the  two 
balls  can  be  placed  opposite  to  each 
other ;  or  the  vaginal  arc  can  be  set 
a  quarter  of  an  inch,  a  half  inch,  or 

Fio.  89.— INSTRUMENT  OP  DR.  BOND,  an  inch  lower  down  than   the   one 


AXTEVERSIOX  OF  THE  UTERUS.       361 

that  is  in  the  rectum.  Upon  being  adjusted,  and  firmly  secured 
by  turning  the  thumb-piece,  it  it  manifest  that  the  two  balls  can 
not  be  separated  from  each  other,  and  that,  if  they  be  moved 
upward,  parallel  with  the  curve  of  the  sacrum  to  the  hight  of  the 
promintory,  they  must  carry  the  retroverted  uterus  before  them, 
and  thus  serve  very  effectually  and  easily  to  reposit  the  dislocated 
organ/' 

747.  In  cases  in  Avhieh  all  measures  are  ineffectual  in  replacing 
the  retroverted  uterus,  two  methods  of  procedure  are  still  open. 
First,  to  leave  the  case   to   nature,  merely  palliating  any  severe 
symptoms  that  may  arise,  but  carefully  keeping  the  bladder  and 
rectum  empty,  and  wait  until  the  uterus,  by  its  increased  size,  has 
elevated  itself   out   of  the   pelvis,    or  until  labor    spontaneously 
occurs.      Or,    secondly,    we    may    induce    premature    labor    by 
puncturing  the   membranes  through   the   os,   or   by  tapping  the 
uterus   through   the   vagina   and   rectum.      Many   objections   are 
urged  against  the   first   of  these  measures,  as,   the  very  severe 
symptoms   which  arise  during    this   condition,    and  which    often 
prove  fatal,  and  the  little  likelihood  of  a  favorable  termination  in 
the  manner  spoken  of.     If,  however,  it  be  adopted,  it  would  be 
well  to  follow  the  advice  of  Denman,  "  to  allow  but  little  liquid, 
keeping    the   bladder   thoroughly    emptied,    by   the    use    of    the 
catheter,  two  or  three  times  a  day,  and  in  maintaining,  for  hours 
together,  an  inverted  position  of  the  pelvis,  by  placing  the  patient 
on   her    knees   and    elbows."     Dr.   Ashwell   says :  —  "  It  is  not 
always  easy  to  puncture  the  membranes  through  the  os,  owing  to 
the  elevated  position  of  the  cervix  ;  and,  if  we  fail  in  repeated 
attempts  to   accomplish   this  purpose,  tapping  the  uterus  is  our 
only  resource.     The  extreme  symptoms  will  not  often  allow  us, 
even  were  we  disposed,  to  content  ourselves  with  drawing  off  the 
water  and  palliating  symptoms  to  the  time  of  labor." 

748.  In  some  cases  where  the  pelvis  is  large,  and  there  is  great 
laxity  of  the  tissues,  it  may  be  proper  to  confine  the  patient  to 
the  horizontal  position,   until  the  uterus  has   arisen   out   of  the 
cavity  of  the  pelvis,  to  prevent  a  re-displacement  of  the  organ. 
These    cases,   however,    are    fortunately   rare,    in    the    most    of 
instances,  keeping  the  bladder  emptied  of  urine,   and  attention 


SG2 


DISEASES     OF    WOMEX. 


to   the   general    health    will   be    found  all-sufficient   to   prevent 
displacement. 

ANTEVERSION  OF  THE  UTERUS. 

749.  This  displacement  is  the  opposite  of  the  one  just 
described,  the  fundus  being  carried  forward  toward  the  sym- 
physis  pubis,  and  the  cervix  uteri  thrown  backward  against  the 
rectum.  It  is  the  least  frequent  of  the  uterine  rnal-positions,  and 
is  very  rarely  met  with,  and  only  in  the  unimpregnated  condition. 
In  this  displacement  we  have  two  varieties,  the  same  as  in  retro- 
version,  anteversion  and  anteflexion;  in  this  last,  the  uterus  is 


FIG.  40. — ANTEVERSION  OF  THE  UTERUS. 


bent  at  the  junction  of  the  cervix  with  the  body  of  the  organ,, 
the  fundus  being  displaced  forward,  while  the  cervix  retains  it& 


ANTE  VERSION     OF     THE     UTERUS.  363 

natural  position,  the  angle  formed  looking  forward  and  downward. 
This  distinction,  though  noticed  by  most  authors,  is  of  very  little 
importance,  the  treatment  of  the  two  conditions  being  exactly 
similar. 

750.  As  has  already  been  stated,  in  the  normal  condition  of  the 
parts,  the  uterus  may  be  said  to  be  slightly  anteverted,  the  direc- 
tion  of  the  uterus   corresponding  with  the   axis  of  the   superior 
strait.     In  this  position,  it  rests  anteriorly  upon  the  bladder,  and 
posteriorly  it  is  in  contact  with  the  rectum.     From  this  oblique 
position  of  the  uterus  in  reference  to  the  axis  of  the  body,  it  is 
obvious  that  the  bladder  in  a  measure  supports  it,  and  that  so  long 
as  the  bladder  is  moderately  distended,  this  accident  may  be  con- 
sidered impossible.     When  it  does  take  place,  the  fundus  uteri  is 
directed  toward  the  inner  surface  of  the  symphysis  pubis,  com- 
pressing the  urethra,  the  entire  organ  being  situated  transversely 
across  the  pelvis. 

751.  Causes. — "  For  the  production  of  anteflexion  or  antever- 
sion,"  says  Dr.  Churchill,  "  it  is  necessary  that  the  fundus  uteri 
should  be  rendered  somewhat  heavier  than  natural,  compared  with 
the  inferior  portion  of  the  organ,  or  else,  that  a  decided  tilting 
forward  should  be  occasioned  by  a  force  external  to  the  uterus. 
This  may  be  effected  in   the  unimpregnated  state  by  means  of 
chronic  enlargement  of  the  anterior  wall,  by  tumors  growing  from 
or  imbedded   in   that  part,    by  great    congestion,    etc.      If    the 
bladder  be  empty,  and  a  sudden  expulsive  force  be  exerted  at  the 
same  time,  the  uterus  may  be  tilted  over  anteriorly,  especially  if 
the  ligaments  have  been  relaxed  by  previous  pregnancies.     Preg- 
nancy, by  increasing  the  weight  of  the  fundus  uteri,  will  so  far 
fulfill  one  of  the  necessary  conditions,  but  the  displacement  can 
only  happen  during  the  first  two  or  three  months.     In  some  cases, 
it  has  been   discovered  that  the  first  displacing  power  resulted 
from    an  accumulation  of  fgeces  high  up   in  the  rectum,   which 
pressed  forward  the  fundus  uteri.    In  others,  an  attack  of  chronic 
metritis  has  rendered  the  womb  top-heavy,  or  the  same  effect  has 
been  produced  by  a  fibrous  tumor,  or  by  miscarriage.     We  must 
also  suppose,  I  think,  that  some  relaxation  has  taken  place  in  the 
surrounding  soft  tissues.     A  blow,  a  fall,  a  shaking  in  an  uneasy 


364:  DISEASES      OF      WOMEN. 

carriage,  obstinate  diarrhea,  have  all  been  enumerated  as  exciting 
causes." 

752.  Symptoms.  —  The    symptoms    of   this   displacement    are 
almost   entirely   mechanical,   and    similar    to   those   produced  by 
retroversion,  though  not  in  general  so  well  marked.     If  the  dis- 
placement comes  on  gradually,  the   symptoms  will  be   so   slight 
that  it  will  be  almost  impossible  to  determine  the  precise  time  of 
their  origin.     The  most  common  symptoms  are  a  sense  of  fullness 
in  the  pelvis,  of  weight  and  bearing  down  low  down  behind  the 
pubis,  accompanied  with  weight  and  pain  in  the   perineum  and 
rectum,    frequent   desire    to    pass    water,    but  great  difficulty  in 
doing  so.     In  some  cases   where    the  displacement   is   suddenly 
produced,  as  by  a  fall,  severe  straining,  as  in  coughing,  vomiting, 
etc.,   the   symptoms   will   be   very  marked,    the  pressure   of   the 
uterus  against  the  urethra   producing  partial,  or  in  some  cases, 
complete  retention  of  urine.     These  symptoms  though  indicating 
disease  of  the  uterus,  are  not  sufficient  to  point  out  the  special 
affection,  as  they  are  common  to  most  all  the  displacements,  and 
to  some  other  diseases  of  these  organs. 

753.  If  a  vaginal  examination  be  made  at  this  time,  the  finger 
will  come  in  contact  with  a  tumor  projecting  into  the  anterior  wall 
of  the  vagina,  and  the  cervix  will  in  anteversion  be  found  thrown 
backward  and  pressing  against  the  rectum.    By  passing  the  finger 
forward  along  the  cervix,  its  connection  with  the  anterior  projec- 
tion can  readily  be  made  out.     The  diagnosis  may  be  assisted  by 
elevating  the   fundus    and  depressing  the  cervix  uteri   with  the 
fingers,  or  if  there  is  no  suspicion  of  pregnancy,  the  uterine  sound 
may  be  used ;  if  this  is  used,  it  will  not  pass  in  the  usual  direction, 
but  the  point  will  have  to  be  directed  much  more  forward,  the 
handle  being  thrown  backward  toward  the  sacrum. 

754.  Diagnosis. — If  the  uterine  sound  be  used,  the  diagnosis 
will  be  very  easily  made  out.     But  without  this,  it  may  be  distin- 
guished from  retroversion  by  the  projecting  tumor  being  in  the 
anterior  wall  of  the  vagina,  and  the  cervix   uteri  being  thrown 
backward  against  the  rectum.     From  pelvic  tumors,  by  tracing 
the  connection  between  the  cervix  and  the  fundus  continuously 
across  the  pelvis,  and  by  trying  to  replace  the  organ,  the  move- 


IXVKRSIOX     OF     THE     UTERUS.  365 

ment  showing  the  connection  between  the  two ;  by  the  same  means 
it  may  be  distinguished  from  ovarian  tumors.  As  showing  the 
importance  of  a  correct  diagnosis,  the  case  of  Leveret  might  be 
cited.  He  confessed  that  the  only  case  of  anteversion  he  ever 
met  with,  he  mistook  for  a  stone  in  the  bladder ;  and  the  mistake 
•was  only  corrected  by  a  post-mortem  examination,  the  woman 
having  died  after  the  operation  for  stone. 

755.  Treatment. — The  treatment  of  this  displacement  is  much 
easier  than   that   of   retrovcrsion ;    the  distention  of  the  bladder 
and  efforts  to  evacuate  the  bowels,  which  tend  to  aggravate  the 
displacement  in  retroversion,  tend  to  replace  the  uterus  in  ante- 
version.     To  replace  the  uterus  the  patient  should  be  placed  upon 
her  back,  with  the  hips  considerably  elevated;  the  cervix  should 
then  be  drawn  down  with  the  fore-finger  of  one  hand,  while   the 
fundus  uteri  is  pushed  up  with  the  other.     The  uterine  sound  may 
also  be  used  to  replace   the  uterus  in  the  same  manner  that  was 
recommended  in  retroversion;  after  the  sound   is  introduced,  by 
drawing  its  handle  forward  the  fundus  uteri  will   be  carried  up 
into  its   natural   position.      Prof.    Godfrey  recommends  that  the 
patients  be  placed  on  the   side  of  the  bed,  with  their  heads  and 
hands  on  the  floor,  with  only  the  anterior  parts  of  the  thighs  and 
legs  resting    on    the    bed.     In    this    position,   the    intestines   are 
drawn  toward  the  diaphragm,  the  pelvis  is  consequently  emptied, 
and    the    uterus,    being    so    pressed    upon,    assumes    its    normal 
situation. 

756.  After  the  uterus  has  been  replaced,  the  patient  should  be 
directed  to  keep  the  bladder  partially  distended  for  some  time, 
to  prevent  a  re-displacement.     In  other  respects  the   treatment 
will  be  similar  to  that  recommended  in  the  other  forms  of  dis- 
placement. 

INVERSION  OF  THE  UTERUS. 

757.  This  displacement  differs  widely  from  prolapse,  for  while 
in  both  there  is  a  descent  or  protrusion  of  the  organ,  in  this  the 
uterus  is  turned   inside -out,  the   mucous   membrane    forming  its 
external   investment,  while    its  cavity,  which  is  directed  upward 
and  contains  the  fallopian  tubes  and  ovaries,  is  lined  by  perito- 


DISEASES     OF     VTOMEX. 


neum.     Fortunately  this  is  the  rarest  form  of  uterine  displace- 
ment, as  it  is  the  most  dangerous. 


FIG.  41. — INVERSION  OF  THE  UTERUS. 

758.  Inversion  of    the  uterus  most  frequently   occurs  imme- 
diately or  soon  after  labor,  though  in  some  rare  instances  it  has 
been  observed  to  occur  in  the  unimpregnated  organ.     Boivin  and 
Duses  divide  this  affection  into  four  degrees,  each  of  which  offer 

O  O  ' 

distinct  characteristics  for  the  diagnosis,  prognosis  and  treatment. 
Each  of  these  degrees  may  succeed  to  each  other,  either  gradu- 
ally or  rapidly;  each  may  also  be  permanent.  The  first  degree 
consists  in  a  simple  depression  of  the  fundus  uteri,  presenting  a 
concave  instead  of  a  convex  surface.  In  the  second  degree  the 
body  of  the  uterus  being  inverted,  falls  into  the  cavity  of  the 
cervix,  and  projects  through  the  os  uteri.  In  the  third  degree, 
the  cervix  is  also  inverted,  the  os  uteri  alone  remaining  unin- 
yerted.  In  the  fourth  degree,  the  entire  uterus  is  inverted  with 
partial  inversion  of  the  vagina,  the  organ  being  passed  through 
the  vulva,  and  hanging  between  the  thighs. 

759.  Causes. — The    causes    producing    this    displacement,    as 
enumerated  by   authors,   are:    hard   or    sudden   traction    on   the 
umbilical  cord,  while  the  uterus  is  in  a  relaxed  condition ;  violent 
pulling  away  of  the  placenta,  while  yet  adherent  to  the  uterus: 


INVERSION     OF     THE     UTERUS.  3G7 

shortness  of  the  umbilical  cord,  or  coiling  of  the  cord  around  the 
neck  or  body  of  the  child,  the  labor  being  rapid ;  the  presence  of 
a  polypus  or  other  tumor  attached  to  the  uterine  wall,  which  by 
its  weight  causes  inversion,  etc.  In  reference  to  the  cause  of  this 
displacement,  Dr.  Tyler  Smith  says  :  "  When  inversion  is  referred 
to  traction  of  the  umbilical  cord,  whether  in  consequence  of  a 
short  funis,  the  sudden  birth  of  the  fetus  while  the  mother  is  in 
an  upright  position,  or  the  attempts  of  the  obstetrician  to  remove 
the  placenta,  it  is  always  believed  to  depend  on  the  merely 
mechanical  force  which  is  in  operation.  It  is  considered  that  the 
fundus  uteri  is  dragged  down  mechanically  through  the  os  uteri 
and  vagina,  the  uterus  being  supposed  to  be  passive  during  the 
occurrence  of  the  inversion.  I  have  always  been  of  the  opinion, 
that,  in  the  gveat  majority  of  cases,  the  accident  happens  in  con- 
sequence of  irregular  but  active  contractions  of  the  uterus  itself. 
No  doubt  cases  may  occur,  in  which  inversion  is  produced  by 
great  tension  upon  the  cord,  while  the  placenta  is  firmly  adherent 
to  the  fundus,  and  that  all  violent  traction  of  the  cord  while  the 
placenta  is  attached  to  the  fundus  is  reprehensible.  But  when 
inversion  is  thus  produced,  there  must  be  a  consenting  action  of 
the  uterus.  This  accident  has  sometimes  happened  when  the 
hand  has  been  introduced  to  peel  off  the  placenta  from  the  fundus, 
when  the  hand,  placenta  and  uterus  have  all  been  forced  out  by 
the  violence  of  the  abnormal  uterine  action.  All  the  facts  con- 
nected with  this  catastrophe,  show  that  it  generally  depends,  not 
upon  a  passive,  but  an  active  condition  of  the  organ.  There  are 
numerous  points  which  prove  that  it  may  happen  spontaneously, 
and  apart  from  all  interference  on  the  part  of  the  accoucheur. 
It  may  occur  after  the  death  of  the  mother,  as  the  result  of  post- 
mortem contraction  of  the  uterus.  Numerous  cases  are  on  record, 
in  which  the  uterus  was  found  inverted,  before  any  attempt  what- 
ever had  been  made  to  remove  the  placenta,  and  while  the  patient 
was  lying  quietly  in  bed.  It  has  even  been  known  to  occur  in  the 
unimpregnated  uterus.  I  have  elsewhere  insisted,  that  the  unim- 
pregnated  and  virgin  uterus,  particularly  under  irritation,  pos- 
sesses more  motor-power  than  is  generally  attributed  to  it.  The 
nulliparous  organ  has  been  known  to  invert  itself,  as  the  result  of 


368  DISEASES     OF      WOMEN. 

spasmodic  action,  in  long  continued  menorrhagia,  or  as  the  result 
of  a  small  polypus  or  fibrous  tumor  in  the  cavity,  or  upon  the 
peritoneal  surface  of  the  fundus.  The  more  this  subject  is 
studied,  the  less  will  it  be  referred  to  merely  mechanical  derange- 
ments." 

760.  Symptoms. — The  symptoms  that  arise  from  acute  inver- 
sion, or  inversion  immediately  after  delivery,  are  always   severe 
and   alarming.     It  produces  violent  disturbance   of  the   nervous 
system,   and  most  generally    copious    hemorrhage.     It  is   said, 
that  the  shock  to  the  system  and  the  hemorrhage,  is  sometimes  as 
great  in  partial  inversion,  as  wrhen  it  is  complete.    The  occurrence 
of  the  displacement  is  marked  by  sudden  exhaustion,  or  sinking, 
the  countenance  becomes  deadly  pale,  the  pulse  rapid,  small  and 
fluttering,  the  voice  weak,  nausea  and  vomiting  occurs,  etc.     Dr. 
Tyler  Smith  states  :   "  That  in  complete  inversion,  the  hemorrhage 
is  somewhat  arrested  by  the  os  uteri  acting  as  a  torniquet  to  the 
uterus.     But  in  either  case,  the  shock  to  the  system  may  be  so 
great,  as  to  cause  death  within  a  short  time  after  the  accident. 
The  shock  is  so  severe  that  a  fatal  result  has  ensued,  when  little 
blood  was  lost,  and  when,  after  a  short  time,  the  re-inversion  of 
the  uterus   was    affected."     There    is    generally    a  very    violent 
uterine  contraction  immediately  preceding  or  accompanying  the 
inversion,  causing  the  patient  to  suspect  a  second  child,  and  the 
passage  of  the  inverted  uterus  along  the  vagina  may   serve  to 
confirm  her  in  this  suspicion. 

761.  On  making  a  vaginal  examination,  instead  of  finding  the 
vagina  free,  the  finger  will  come  in  contact  with  a  tumor,  globular 
in  form,  elastic,  sensible,  and  with  a  rough  and  bleeding  surface. 
This  tumor  may   only  partially  fill  the  vagina,  or  it  may  pass 
down  to  the  vulva,  resting  on  the  perineum,  as  in   the  forms  of 
incomplete  inversion  spoken  of;  or  it  may  have  passed  through 
the  vulva,  and  be  situated  between  the  patient's  thighs.     If  the 
placenta  be  still  attached  to  it,  it  will  increase  the  size  of  the 
tumor,  and  make  the  diagnosis  much  easier. 

762.  In  the  chronic  form  of  the  displacement,  which  is  extremely 
rarely  met  with,  the  symptoms  vary  so  much,  that  their  enumera- 
tion would  add  nothing  to  our  practical  knowledge  of  the  displace- 


INVERSION  OF  THE  UTERUS.         369 

ment.  In  some  cases  reported,  the  inversion  had  been  of  years' 
standing,  and  yet  the  patients  enjoyed  a  tolerable  degree  of 
health ;  and  in  none  of  these  cases  have  the  symptoms  been  more 
severe  than  in  cases  of  complete  prolapse,  in  fact,  those  described 
would  answer  as  well  for  the  one  displacement  as  the  other. 

763.  Diagnosis. — The  diagnosis  of  this  displacement  is  quite 
easy  when  the  placenta  is  adherent  to  the  inverted  uterus ;  but 
when  the  placenta  has  been  previously  expelled,  and  nothing  but 
the  inverted  uterus  felt  in  the  vagina,  there  are    circumstances 
which    make    it    quite   hard    to   determine    the    character  of  the 
affection.     Dr.  Tyler  Smith  says  :  "  In  true  inversion,  the  globular 
wall  of  the  uterus  is  entirely  absent  from  the  hypogastrium,  and 
a  bleeding  mass  is  found  in  the  vagina,  or  protruding  externally. 
This   mass    may,   however,  be    simulated    to    some    extent   by    a 
prolapsus  or  procidentia,   occurring  immediately  after  labor,  or 
by  the  extrusion  of  a  polypoid  tumor  after  the  expulsion  of  the 
placenta.     In  the  case  of  the  prolapsed  or  procident  uterus,  the 
diagnosis  is  easy,  from  the  presence  of  the  os  uteri  in  the  most 
depending  part  of  the  tumor.     The  distinction  between  polypus 
and  inversion  is  riot  so  easy,  particularly  when  the  polypus  is  of  a 
fibrous  character,  and  of  the  same  density  and  structure  as  the 
walls  of  the  uterus  itself.     In  the  case  of  polypus,  there  is  the 
sensation  of  a  solid  mass  ;  and  in  inversion,  that  of  a  hollow  organ 
is  conveyed  to  the  finger.    When  punctured  or  pricked,  the  uterus 
is  said  to  be  much  more  sensitive  to  pain  than  the  polypoid  tumor. 
In  complete  inversion,  the  fossa  round  the  base  of  the  tumor  is 
limited  in  extent,  while  in  polypus  the  finger  may  be  passed  into 
the  cavity  of  the  organ,  the   pedicle  can   generally  be  felt,  and 
there  is  the   uterine   tumor   in   the  lower   part  of  the  abdomen. 
Great  care  is  required  in  the  diagnosis,  as  cases  have  occurred  in 
which  a  polypus  has  been  mistaken  for  an  inverted  uterus,  and,  in 
some  instances,  inversion  has  occurred  without  the  accident  having 
been  recognized  at  all,  until  long  after  the  time  of  labor. 

764.  Treatment. — Where  the  inversion  has  taken  place  imme- 
diately  after  delivery,  the   reposition    of  the    uterus    should   be 
undertaken  as  soon  as  possible.     It  is  laid  down  as  a  rule,  that 

the  sooner  the  reduction  is  attempted  the  easier  it  may  be  accom- 
24 


370  DISEASES     OF     WOMEN. 

plished,  on  account  of  the  rapidly  increasing  contraction  of  the 
os  uteri,  which,  by  impeding  the  circulation  of  the  uterus,  causes 
an  increase  in  its  size.  Though  the  most  favorable  time  for  the 
reposition  of  the  uterus  is  immediately  after  the  accident,  yet  we 
should  not  consider  the  case  hopeless,  though  it  was  of  several 
days'  standing.  Many  cases  are  reported  in  which  the  reduction 
was  effected  after  from  ten  to  twenty-four  hours  had  elapsed, 
others  after  the  lapse  of  from  three  days  to  twelve  weeks,  and 
one  of  fifteen  months'  standing,  under  the  influence  of  chloroform. 

765.  In  the  incomplete  form  of  inversion,  two  or  three  fingers 
of  one  hand  may  be  introduced  into  the  vagina,  and  the  fundus 
uteri  carried  up  through  the  os  to  its  proper  position.     It  would 
be  well  to  follow  the  recommendation  of  Prof.   Meigs,  to  make 
compression  on  the  uterus  only  during  the  absence  of  contraction, 
and  when  the  organ  is  somewhat  flaccid.     After  the  reposition  of 
the    organ,    the    fingers    should    not    be    withdrawn    until    after 
contractions    have    taken    place,   as    otherwise    the    displacement 
might  speedily  recur. 

766.  In  complete  inversion  the  placenta  should  be  detached,  if 
it  adheres,  so  as  to  reduce  the  bulk  of  the  tumor,  and   it  is  also 
advised  by  some  authors,  to  reduce  the  size  of  the  uterus,  as  much 
as  possible,  by  pressure.     Then  when  contraction  of  the  uterus  is 
absent,  and  it  is  somewhat  flaccid,  the  hand,  well  oiled,  should  be 
pressed  against  the  center  of  the  fundus  so  as  to  indent  it,  and 
then  by  moderate  but  sustained  pressure,  the  fundus  should  be 
carried  up  through  the  body  cervix  and  os  uteri,  to  its  proper 
position.     Dr.   Dewees   and   others    recommend   that   the   globe 
should  be  grasped  with  the  hand,  and   the  entire    mass   pushed 
upward  into  the  pelvis.     Dr.  Meigs,  in  a  note  to  M.  Colombat, 
reports  a  case  in  which  he  tried  the  method  of  Dr.  Dewees,  but 
without  the  least  success ;  he  says :  "  After  I  had  removed  the 
after-birth,  I  found  that  the  organ  became  alternately  soft  and 
rigid,  just  as  happens  after  delivery  in  an  ordinary  labor ;  and  1 
further  observed  that  to  handle  it  was  to  irritate  its  contractility 
and  to  harden  it,  which  rendered  it  obdurate  against  every  attempt 
at  reduction.     I  was  compelled,  therefore,  to  do  what  M.  Colombat 
so  pointedly  condemns :  i.e.,  to  wait  until  it  became  relaxed,,  and 


INVERSION  OF  THE  UTERUS.       371 

then  indent  the  fundus,  and  to  drive  that  cone  up  through  the 
cervix  and  os  uteri,  until  1  had  carried  my  hand  so  high  that  the 
external  organs  contained  my  arm  to  not  more  than  four  or  five 

CD  «/ 

inches  helow  the  elbow.  I  feel  very  confident  that  if,  in  any  case, 
I  could  succeed  in  indenting  a  fundus  uteri,  and  in  bringing  the 
cone  up  to  the  os  uteri,  I  could  always  perfect  the  operation  by 
gently  pressing  that  cone  against  the  ostium  uteri,  which,  under  a 
persevering  maintenance  of  the  pressure,  would  yield  as  readily 
as  it  does  to  a  labor-pain,  or  to  the  cone  of  the  hand,  when 
introduced  in  cases  of  hour-glass  contraction  or  spasm  of  the 
cervix  under  encysted  or  retained  placenta.  [  dare  recommend 
to  the  reader,  therefore,  to  disregard  the  author's  injunction,  and 
to  adopt  the  method  which  I  have  found  successful.'' 

767.  After  the  uterus   has  been  replaced,  the  hand  should  by 
no  means  be  withdrawn,  until   the  uterus  has  contracted  to  expel 
it,  and  until  it  is  certain  that  the  restoration  is  complete.     It  is 
recommended    that    the    patient    should    be    kept    longer    in    the 
horizontal  position   than  usual,  and  that  she  should  lay  vrith  the 
pelvis  somewhat  elevated.      The  exhaustion  and  depression  of  the 
system   should    be    removed    by   appropriate    stimuli,    and    other 
measures,  the  same  as  if  they  had  occurred  from  any  other  cause 
at  this  period. 

768.  Where  the  inversion  has  been  of  several  days'  standing, 
it  would   probably  be  advisable   to   place   the  patient   under   the 
influence  of  chloroform  before  attempting  the  reposition.     In  the 
case    of   M.  Barrier,    the   displacement    was    of   fifteen    months' 
standing,  and  the  reduction  was  accomplished  under  the  influence 
of  chloroform. 

769.  In  cases  of  long  standing,  where  reduction  was  impossible, 
it  has  been  recommended  to  replace  the  uterus  in  the  vagina  and 
to  sustain  it  there  by  means  of  the  perinea!  supporter  heretofore 
described.    This,  when  it  can  be  accomplished,  would  be  decidedly 
the  best  treatment.     Again,  it  is  recommended  to  extirpate   or 
remove   the   uterus,  either  by  means  of   the  ligature,  or   by  the 
knife.     This  operation  has  proved  successful   in  many  cases,  and 
in  other  cases   it  was  less  fortunate,  the    patient   surviving  the 
-operation  but  a  short  time.     If  the  ligature  is  employed,  it  should 


372  DISEASES    OF    WOMEN. 

be  of  stout  silk  or  whip-cord,  and  applied  around  the  tumor  at  its 
highest  part;  this  should  be  gradually  tightened  as  the  patient 
may  be  able  to  bear  it,  until  the  tumor  has  sloughed  off.  Or 
after  the  ligature  has  been  applied  and  tightened  sufficiently  to 
strangulate  the  viscus,  it  may  be  detached  with  the  knife,  cutting 
below  the  ligature. 

770.  The  symptoms  that  arise  from  the  application  of  the 
ligature  are  so  severe,  that  many  times  it  has  to  be  loosened  until 
they  have  passed  off,  and  in  some  cases  it  has  been  followed  by  a 
fatal  result.  From  the  experiments  that  have  been  made  with  the 
"  ecraseur,"  I  would  suppose  that  this  instrument  would  be  more 
applicable  in  these  cases  than  any  other  mode  of  extirpation  that 
has  heretofore  been  recommended,  its  operation  being  quick,  not 
followed  by  hemorrhage,  and  accomplished  while  the  patient  is 
under  the  influence  of  chloroform. 


CHAPTER     XII. 


DISEASES  OF  THE  FALLOPIAN  TUBES  AND  OVARIES. 

771.  The  connection  existing  between  the  fallopian  tubes  and 
ovaries,  and  more  especially  their  anatomical  position,  being 
situated  closely  together  between  the  layers  of  the  broad  liga- 
ments, and  at  the  sides  and  somewhat  posterior  to  the  uterus, 
make  it  impossible  to  distinguish  during  life  between  the  affections 
of  the  tubes  and  of  the  ovaries.  Diseases  of  the  tubes  and  ovaries, 
likewise,  give  rise  to  similar  symptoms,  and  require  the  same 
treatment,  so  that  for  practical  purposes  no  advantage  can  be 
gained  by  their  separate  consideration.  Yet  it  may  be  interest- 
ing to  the  reader  to  point  out  the  morbid  processes  to  which  the 
tubes  are  liable. 


INFLAMMATION    OF    THE    FALLOPIAN    TUBES.        373 

INFLAMMATION  OF  THE  FALLOPIAN  TUBES. 

772.  This  is  said  to  be  a  very  common  disease,  and  resembles, 
in  all  its  features,  inflammation  of  the  mucous  membrane  of  the 
uterus  or  internal  metritis.    In  the  non-puerperal  state  the  inflam- 
mation is  principally  confined  to  the  mucous  membrane  lining  its 
cavity.     It  may  arise  from  inflammation  of  the  uterus  extending 
by  the  continuity  of  its  tissues,  or  from  the  same  disease  of  the 
ovaries,  and  also  it  is  said  from  acute  suppression  of  the  menses. 
This    inflammation    may  be  either  acute  or  chronic,  though  the 
acute  stage  soon  terminates  in  the  chronic  form. 

773.  Inflammation  of  the  fallopian  tube  causes  a  thickening  of 
the  mucous  membrane,  which  is  tumefied,  purple  or  slate  colored ; 
the  tube  is  variously  dilated,   and  its   course   tortuous.     It  also 
gives  rise  to  an  increased  secretion  of  the  natural  mucus,  which 
may  be  viscid  and  transparent,  of  a  yellowish-white  color,  or  a 
bluish-gray,   or  yellow  purulent  mucus.     Acute  inflammation  at 
either  extremity  of  the  tube  may  give  rise  to  an  occlusion  of  its 
canal,  and  consequent  sterility. 

774.  Occlusion  of  the  extremities  of  the  tubes  may  likewise 
give  rise  to  that  condition  known  as  dropsy  of  the  tubes.    Accord- 
ing to  Prof.    Rokitansky  this  dropsical    condition    of  the    tubes 
arises  from  the  accumulation  of  the  secretion  of  the  mucous  mem- 
brane, and  from  this  accumulation,  the  tube,  especially  toward  its 
fimbriated  extremity,  becomes  so  much  distended,  that  that  which 
before  represented  a  tortuous  or  bent  channel,  is  now  converted 
into   a  simple  sac.     At  other  times,  several  saccular  dilatations 
form  between  the  separate  angles  and  the  projecting  duplicatures 
of  the  tubal  parieties,  and  give  rise  to  an  imperfectly  loculated 
pouch,  which,  as  in  the  former   case,  may  contain  blennorrhoid 
mucus,  a  puriform  secretion,  a  true  purulent  inflammatory  pro- 
duct, or,  if  the  mucous  membrane  has  become  altered,  fluids  of 
another  description.     It  is  to  be  observed,  that,  as  the  dilatation 
proceeds,  the  texture  of  the  mucous  membrane  is  changed,  being 
-converted  into  a  serous  membrane  ;  its  secretion  may  be  a  thin 
watery,  serous,  colorless  liquid,  giving  the  tube  the  appearance  of 
ti  transparent  sero-fibrous  bladder:  or  it  may  be  variously  colored, 


374  DISEASES    OF     WOMEN. 

yellowish,  brown,  blackish-green,  arid  more  thick  and  flocculentr 
consisting  in  part  of  inflammatory  products  on  the  internal  surface 
of  the  membrane. 

775.  The  hydropic  fallopian  tube  not  unfrequently  attains  the 
size  of  a  duck's  or  goose's  egg,  or  even  of  a  man's  fist ;  although 
not  a  usual  occurrence,  still  it  is   satisfactorily  proved  that  the 
contents    are    sometimes    discharged   into    the    uterus,    and    thus 
carried  off. 

The  symptoms  and  treatment  of  this  disease  will  be  the  same  as 
in  ovaritis. 

INFLAMMATION  OF  THE  OVARIES. 

776.  Inflammation  of  the  ovaries  is  a  rare  disease  when  occur- 
ring as  a  separate  and  isolated  affection  apart  from  the  puerperal 
state ;  still  it  does  occur  sufficiently  often  to  demand  a  separate 
consideration.     Puerperal    inflammation    of    the    ovaries    will  be 
considered  in  the  chapter  on  puerperal  fever. 

777.  The  seat  of  this  inflammation,  according  to  Prof.  Roki- 
tansky,  is  in  the  follicles  or  Graafian  vesicles.      He  says,  "  The 
coats  of  a  follicle  are  occasionally  found  injected,  reddened,  soft- 
ened, and  friable  ;  the  contents  are  opaque,  flocculent,  reddened 
by  an  admixture  of  blood,  and  not  unfrequently  purulent.     This 
process,  even  in  its  slightest  form,  is  followed  by  the  destruction 
of  the  germ  by  means  of  the  exudation  ;  obliteration  of  the  follicle 
soon  ensues,  and  the  first  impulse  is  thus  given  to  its  conversion 
into  a  common  serous  cyst,  which,  in  its   turn,  may  grow  into 
ovarian  dropsy." 

778.  Causes. — Inflammation  of   the    ovaries,    it  is    said,    may 
arise  from   a   blow  received   in   the   iliac   regions,  from   sudden 
suppression  of  the  menses,  etc.     In  other  cases  it  may  arise  like 
inflammation    of  any   other  part  of    the   uterine    system, — from 
exposure  to  cold,  to  sudden  changes  of  temperature,  etc. 

779.  Symptoms. — In  the  acute  form  of  the  disease,  the  patient 
will  complain  of  a  dull,  aching  pain  in  one  or  both  of  the  iliac 
regions,  deeply  seated,  and  accompanied  with  sensations  of  weight 
and   heat,  always    aggravated   by  the    erect   posture,  or   by  any 
sudden  movement,  and  by  defecation.    These  symptoms  are  some- 
times preceded  by  a  slight  chili,  followed  by  some  fever,  at  other 


INFLAMMATION     OF     THE     OVARIES.  O/O 

times,  the  fever  does  not  make  its  appearance  until  after  tl'.e  local 
symptoms  are  developed.  The  fever  is  never  very  high,  and  is 
generally  intermittent ;  the  paroxysms  occurring  generally  in  the 
afternoon  or  evening.  Pressure  over  the  inflamed  ovary  will 
generally  increase  the  pain.  M.  Portal  observes,  "  that  he  has 
often  been  with  patients  affected  with  ovaritis,  who  had  experienced 
all  the  pathognomonic  symptoms  of  inflammation  of  the  uterus, 
but  who,  after  the  lapse  of  some  time,  and  subsequently  to  their 
apparent  recovery,  became  the  subjects  of  fullness,  and  in  fact  of 
very  great  intumescence  in  one  or  both  iliac  regions,  for  which 
they  took  various  remedies  without  advantage.  On  inspecting 
the  bodies  of  such  persons  after  death,  he  found  the  uterus 
perfectly  healthy,  while  the  ovary  of  one  side,  and  in  other  cases 
of  both  sides,  together  with  the  ligament  or  ligaments,  round  and 
broad,  of  either  or  both  sides,  presented  the  appearance  of  great 
engorgement." 

780.  Inflammation  of  the  ovaries  always  interferes  more  or  less 
with    the    uterine   functions,    checking    menstruation    during    its 
existence,  and,  if  it  goes  on  to  produce  structural  changes,  it  may 
be  the  cause  of  sterility. 

781.  Acute  inflammation  of  the  ovaries  may  terminate  in  reso- 
lution, or  in  the  chronic  form  of  the  disease,  or  in  some  rare  cases 
it  may  terminate  in  suppuration ;  the  pus  being  contained  in  but 
a  single  enlarged  Graafian  vesicle,  or  the   entire  ovary  may  be 
involved  in  the  abscess.     The  termination  in  suppuration  will  be 
indicated  by  rigors,  and  a  mitigation  of  the  general  symptoms ; 
the    pain    is    also    lessened,    and    succeeded    by    a  sensation    of 
throbbing  and  increased  weight ;    in  these  cases,  there  is  also  a 
considerable  enlargement  in  the  iliac  region.     The  symptoms  in 
this  case    somewhat  resemble  those  of  ovarian  dropsy.     The  two 
diseases  maybe  distinguished,  says  Boivin  and  Duges ;  "for,  in 
dropsy,  there  is  a  more   evident   and   uniform   fluctuation,  more 
considerable  volume,  higher  ascent  into  the  abdomen,  pain  and 
tenderness  only  at  a  late  period ;  in  inflammation    of  the  ovary 
there  is  partial  fluctuation,    hardness  in  several  pa-rts,  pain  and 
tenderness  at  the  first  moments  of  turgidity,  seated  in  the  pelvia 
or  at  its  circumference." 


376  DISEASES     OF     WOMEN. 

782.  Chronic  inflammation  of  the  ovaries  is,  in  almost  every 
case,  the  sequence  of  the  acute  form,  and  its  symptoms  are  similar 
but  more  obscure.     In  this  form  of  the  disease,  there  will  always 
be  more   or  less   enlargement  in  the   iliac  region,  with   a  deep- 
seated  and  dull  pain,  tenderness  on  pressure,  and  a  sensation  of 
weight  in   the   pelvis.     These  symptoms  are  occasionally  aggra- 
vated by  exercise  in  the  erect  position,  and  sometimes  during  the 
evacuation  of  the  urine  and  faeces. 

783.  Diagnosis. — If  we  depended  on  the  symptoms  presented 
by  the  disease,  the  diagnosis  would  be  very  obscure,  as  the  same 
symptoms  are  presented  by  other  diseases  of  the  uterus  and   its 
appendages.      Thus,   in    inflammation    of    the    cervix    uteri,    the 
pain  in   the    ovarian   regions   is   so  constant,   as  to  be  almost  a 
pathognomic  symptom.     The  absence,  however,  of  disease  of  the 
cervix  uteri,  or  of  any  portion  of  the  uterus  which  may  be  ascer- 
tained by  examination,  would  make  it  probable  that  the  symptoms 
were  produced  by  ovarian  inflammation.     The  diagnosis  may  also 
be  assisted  by  a  rectal  examination,  the  finger  introduced  into  the 
rectum  can  feel  the  enlarged  ovary,  which  is  sensitive  to  pressure. 

784.  Treatment. — The  treatment  of  inflammation  of  the  ovary 
is  similar  to  that  recommended  for  metritis.     In  the  acute  stage 
of  the  disease,  prescribe  the  special  sedative,  Aconite  or  Yera- 
trum,  as  indicated  by  the  pulse,  associating  with  it  any  agents 
that  may  be  called  for.     In  some  cases  the  tensive,  dragging  pain, 
backache,  and  soreness  of  muscles,  call  for  Macrotys  so  distinctly 
that  one  can  not  make  a  mistake.     In  others  the  burning  pain  in 
the  part,  sometimes  extending  to  the  vagina,  with  frontal  head- 
ache and  sharp  stroke  of  the  pulse,  calls  for  Rhus.     The  scanty 
urine,  with  tenesmus,  and  frequently  irritation  and  determination 
of  blood  to  the  brain,  calls  for  Gelseminum.     The  dull,  stupid 
headache,  with  inclination  to  sleep,  and  especially  if  associated 
with  "  hives,"  calls  for  Belladonna.     The  steady  pain   extending 
to  the  groin  is  an  indication  for  Bryonia;  uterine  tenesmus  for 
Viburnum  ;  and  dragging  in  the  groins  and  vulva,  Phytolacca. 

785  In  many  cases  we  will  find  the  patient  with  a  bad  breath, 
and  a  heavily  coated  tongue.  The  remedy  is  of  course  not  always 
Sulphite  of  Soda,  but  the  pallid  dirty  tongue  will  tell  the  story. 


INFLAMMATION     OF     THE     OVARIES.  377 

If  at  the  menstrual  period  there  is  fetor,  give  Chlorate  of  Potash. 
Cathartics  should  be  carefully  used — a  Seidlitz  Powder,  "salts 
and  sulphur,"  citrate  of  Magnesia,  rather  than  the  harsher  vege- 
table cathartics.  Still  there  are  some  cases  where  the  old-fash- 
ioned compound  powder  of  Jalap,  or  Podophyllin,  will  prove  of 
advantage. 

786.  Fomentations  of  hops,   stramonium,  water-pepper,  etc., 
may  be  employed  at  first,  or  what  is  better,  a  surface  of  two  or 
three   inches   may  be   painted  with   Aconite  and  Yeratrum,  and 
then  a  sponge  or  flannel  wrung  out  of  hot  water  applied.     Chlo- 
roform counter-irritation  maybe  used  in  some  cases,  but  as  a  rule 
the  ordinary  counter-irritant  does  more  harm  than  good. 

787.  In  the  sub-acute  or  chronic  form  of  the  disease,  the  irri- 
tating plaster  may  be  applied  over  the  diseased   ovary,  and  the 
treatment  named  for  chronic  metritis  will  be  applicable  here. 

788.  In  regard  to  its  termination  in  suppuration,  Dr.  Ashwell 
says :   "  If  matter  does  form,  we  must  watch  its  progress ;  for  it 
may  point  either  in  the  iliac  fossa  itself,  or  lower  in  the  groin. 
If  the  pain  be  not  acute,  or  the  patient  too  much  exhausted,  we 
may  permit  the  abscess  to  open  spontaneously ;  but  if,  from  feeble 
powers,  or  the  thickness  and  induration  of  the  integuments,  this 
should  be  a  prolonged  process,   then  we  open  it  either  by  the 
lancet  or  caustic.     The  former  is  the  easier ;  the  latter,  from  its 
producing  adhesions  between  the  ovary  and  peritoneum,  and  thus 
preventing  the   escape  of   pus  into  the  peritoneum   or   cellular 
tissue  of  the  pelvis,  is  the  safer  method.     If  matter  be  discovered 
through  the  walls  of  the  vagina,  an  opening  may  be  made  either 
•with   a   small  trocar   or  lancet.     Doubtless,  in  cases  so   full  of 
interest,  every   precaution   must   be    observed,    both    as   to   the 
general  treatment  and  the  evacuation  of  the  pus.     It  can  scarcely 
be  too  strongly  urged,  that  sexual  intercourse  be  avoided  for  some 
time,  at  least  till  the  health  is  restored,  and   the  local  ovarian 
irritation  has  subsided.     The  published  cases  prove  that  in  some 
instances,  there  is  a  proneness  to  the  repetition  of  the  malady." 

OVARIAN  DROPSY. 

789.  This  name  has  been  given  to  an  accumulation  of  fluid 
-contained  in  one  or  more  cysts,  which  have  their  origin  from  the 


378  DISEASES     OF     WOMEN". 

substance  of  the  ovary.  Unlike  other  forms  of  dropsy,  the  fluid 
here  is  secreted  by  a  new  and  abnormal  formation,  and  though  it 
is  furnished  with  vessels  and  capable  of  rapidly  secreting  an 
enormous  quantity  of  fluid,  yet  this  cyst-wall  is  incapable  of  reiib- 
sorbing  the  eifused  fluid.  Thus  we  will  see  the  marked  difference 
between  this  and  other  dropsical  diseases,  if  we  compare  it  with 
ascites,  or  abdominal  dropsy.  In  this  last  form  of  dropsy  the 
fluid  is  effused  from  a  structure  capable  of  absorption,  and  though 
the  effused  fluid  is  similar  in  both  diseases,  yet  in  this,  if  the 
blood-vessels  are  emptied  by  copious  diuresis,  or  by  the  action  of 
hydragogue  cathartics,  the  fluid  effused  into  the  peritoneal  sac 
will  be  reabsorbed  and  carried  out  of  the  system.  In  encysted 
dropsy,  however,  no  matter  hoAY  copious  the  discharge  of  fluid  is 
from  the  kidneys  or  bowels,  not  the  least  effect  is  produced  on 
the  local  dropsy. 

790.  The  pathology  of  ovarian  dropsy  has  been  minutely  in- 
vestigated of  late  years,  by  many  eminent  observers,  and  though 
the  causes  of  the  morbid  cyst-production  is  still  involved  in  much 
obscurity,  yet  we  have  a  very  complete  history  of  their  anatomical 
structure  and  mode  of  growth. 

791.  Ovarian  cysts  are  divided  into  two  classes,  the  simple  or 
unilocular  cyst,  and   the   multilocular  or  proliferous  cysts.     The 
first  are  called   simple  or  unilocular,  because   but   one  cyst   is 
found  growing  from  the  ovary,  and  which  contains  the  entire  fluid, 
and   has    no   power  to   reproduce    similar  cyst-structures.     The 
second   variety  or  proliferous   cysts   are    those  whose   parieties 
present  the  very  remarkable  character  of  producing  other  cysts 
of  a  similar  character  with  themselves. 

792.  Simple  Cysts. — Though  I  have  already  stated  that  the 
characteristics  of  the  simple  cyst  was,  its  separate  existence  or 
origin  from  the   ovary,  and  a  want  of  power  to  give  origin  to 
similar  formations,  yet  many  authors  make  their  want  of  repro- 
ductive power  the  characteristic  difference  between  them  and  the 
proliferous  cysts,  and  not  their  separate  existence  in  connection 
with  the  ovary.     It   must  be   recollected,  then,   that  the   term 
unilocular  as  used  by  some  authors,  is  not  applied  to  the  single 


OVARIAN    DROPSY.  379 

cyst,  but  to  any  and  all  cysts  which  have  a  separate  origin  from 
the  ovary. 

793.  In  reference  to  the  simple  cysts,  Prof.  Rokitansky  says : 
"  There  are  either  one  or  several  unilocular  cysts  in  the  ovary ; 
at  times  they  are  even  so  numerous,  that  the  ovary  appears  con- 
verted into  an  aggregation  of  cysts.      They  are  placed  near  one 
another,  each  being   formed  from  the   stroma,  independently  of 
each  other,  and  they  have  a  rounded  form.     If  they  enlarge,  they 
come  into  mutual  contact,  their  parieties  adhere  to  one  another, 
and  they   are   flattened  by  reciprocal  pressure ;    the   impression 
may  thus  arise,  that  several  have,  in  the  manner  of  the  compound 
cysts,  been  formed  within  the  parieties  of  the  same  matrix.     They 
attain  a  considerable  size,  rarely,  however,  exceeding  that  of  a 
man's  head.     In  this   case  the  solitary  cyst,  or   one  of  several 
cysts,  undergoes  extreme  development,  while    the   remainder  con- 
tinue   undeveloped.     They    generally    have    delicate    sere-fibrous 
parieties,  and  may  contain  a  colorless,  or  pale  yellowish  or  green- 
ish, serous,  or  a  more  consistent  yellow,  brownish,  colloid  sub- 
stance, or  an  opaque,  chocolate-colored  or  inky  fluid.     In  many 
cases  they  are  undoubtedly  formed  from  Graafian  follicles,  and  it 
appears  that  an  inflammatory  process  is  particularly  liable  to  give 
the    first    impulse    to   this    metamorphosis.     They    are    probably, 
however,  as  often  new  formations  from  the  beginning ;  and  this  is 
the  more  likely  in  those  cases  in  which  their  number  exceeds  the 
average  number  of  Graafian  follicles." 

794.  Multiloeular  or  Proliferous  Cysts. — These  cysts,  like  the 
former,  are  supposed  to  arise  from  the  Graafian  follicles,  and  they 
may  be  developed  in  the  first  instance  as  simple  cysts,  but  in  time 
they  become    proliferous,   giving   origin  to   numerous   cysts  of  a 
similar  character.     The  cysts  produced  from  the  parent  structure 
may  arise  from  the  internal  surface  and  project  inward,  attached 
to  the  original  cyst-wall  by  a  pedicle,  or  by  a  broad  base  ;  they 
also  vary  much  in  number  and  in  size.     In  some  cases  the  parent 
cyst  will  be  found  filled  with  these  secondary  growths  of  various 
sizes,  each  containing  a  portion  of  the  enclosed  fluid.     Again,  the 
secondary  cysts  may  arise  from  the  external  surface  of  the  parent 
cyst,  and  project  outward  from  it.     These  proliferous  cysts  are 


380  DISEASES     OF     WOMEN. 

capable  of  much  greater  development  than  the  simple  variety ; 
and  to  them  and  the  next  variety  most  of  the  large  encysted 
ovarian  dropsies  are  due. 

795.  Prof.  Rokitansky  describes  a  third'  form  of  cyst,  which 
closely  resembles  and  belongs  to  the  proliferous  variety;  he  states 
that  it  is  of  a  cancerous  nature,  and  belongs  to  the  areolar  variety 
of  carcinoma.  "  In  the  shape  which  we  are  about  to  describe,  it 
rarely  occurs  any  where  but  in  the  ovary.  It  is  an  accumulation 
of  numerous  fibrous  sacs,  which  contain  various  substances,  but 
for  the  most  part  a  glutinous,  viscid  matter.  They  diminish  in 
size  from  the  circumference  toward  the  interior,  and  especially 
toward  the  base  of  the  morbid  growth ;  so  that  the  latter  repre- 
sents a  condensed  alveolar  mass,  the  alveoli  or  follicles  of  which 
consist  of  a  white,  shining,  fibrous  tissue,  and  contain  a  colorless 
or  grayish,  yellowish,  yellowish-green,  or  reddish  viscid  gelatine. 
We  have  here  an  areolar  cancer,  the  peripheral  follicles  of  which 
are  converted  into  large  sacs.  This  species  of  dropsy,  which,  for 
the  sake  of  distinction  from  the  other  varieties,  we  term  alveolar 
dropsy,  is  proved  to  be  malignant,  not  only  by  its  being  accom- 
panied by  well-marked  cachexia,  but  also  by  its  complication  with 
cancer  (especially  of  the  medullary  variety)  in  the  same  organ, 
arid  with  other  varieties  of  cancer  in  other  organs,  as  the  perito- 
neum, stomach,  etc." 

796.  Structure. — The  cyst-wall  is  said  to  consist  of  three 
coats — an  external  peritoneal,  a  middle  fibrous,  and  an  internal 
fibrous,  but  smooth,  and  capable  of  secreting,  though  not  of 
absorbing  fluid.  The  thickness  of  the  cyst-wall  varies  in  different 
cases,  and  even  in  different  parts  of  the  same  cyst ;  and  when 
there  are  several  cysts,  there  will  often  be  considerable  difference 
in  the  thickness  of  their  walls.  Sometimes  the  walls  are  as  thin 
as  brown-paper,  and  they  vary  from  this  to  an  inch  in  thickness. 
The  ovarian  cyst  is  sometimes  very  sparsely  supplied  with  blood- 
vessels, as  is  very  generally  the  case  with  the  simple  cyst ;  but  at 
other  times  they  are  very  numerous  and  large.  Cruveilheir  con- 
siders them  to  he  principally  veins,  but  Delpech,  who  has  carefully 
dissected  them,  considers  them  to  be  arteries ;  he  has  found  them 
as  large  as  the  little  finger.  The  arteries  of  the  cyst  arise  from 


OVAUIA.X     DROPSY.  381 

the  ovarian  arteries,  and  the  veins  empty  into  the  ovarian  veins; 
both  sets  of  vessels  arc  found  in  the  middle  coat. 

797.  We  have  next  to  consider  the  structure  and  character  of 
the  pedicle,  a  point  that  has  been  overlooked  by  most  authors  on 
this  subject.     If  we  trace  an  ovarian  tumor,  whether  consisting  of 
one  or  of  many  cysts,  from  the  surface  inward   to  its  attachment, 
we  find  that  it  gradually  grows  less  in  size,  the  walls  being  nearer 
in   apposition,  until   within   a   short   distance  of   the   ovary  they 
become   consolidated,  forming   a  solid  stalk  of  fibrous   tissue  of 
variable   thickness.      Within    this    pedicle    are    the   blood-vessels 
which  pass  to  and  from  the  cyst.     The  length  of  the  pedicle  varies 
in  different  cases ;  sometimes  it  is  as  much  as  two  or  three  inches 
in  length,  and  flexible ;  at  others,  it  is  very  short,  not  more  than 
half  an  inch  in  length.     The  pedicle  likewise  varies  in  thickness 
according   to   the    thickness    of   the    cyst-walls,    and    from    other 
circumstances  ;  sometimes  it  is  not  thicker  than  the  little  finger, 
at  others  one  or  two  inches   in  thickness.     In   the   majority  of 
cases  the  attachment  of  the  pedicle  is  directly  to  the  ovary,  this 
organ  being  but   slightly  changed   in   structure;   in  other  cases, 
however,  the  ovary  may  be  very  much  changed  in  structure,  or  it 
may  have  entirely  disappeared,  or  its  remains  may  form  a  sort  of 
knot  on  one  of  the  parieties  of  the  cyst.     In  either  case,  however, 
the  point  of  its  attachment  will  be  the  same,  as  its  vessels  are 
derived  from  the  ovarian  vessels,  and  these  retain  it  in  its  position. 

798.  If  inflammation  should  have  occurred,  either  in  the  cyst 
itself  or  in  the  adjoining  structures,  from  its  presence,  adhesions 
may  form  between  it  and  any  of  the  adjoining  viscera.     Thus,  it 
has  been  found  attached  to  the  fallopian  tubes,  to  the  uterus,  to 
the  intestines,  to  the  liver,  the  abdominal  walls,  both  anterior  and 
posterior,  and  in  fact  to  any  part  of  the  abdomen  or  its  contents 
with    which   it   may    be    in   relation.       The    character    of   these 
adhesions  are  various  ;    sometimes   they   are   but   slight,   readily 
broken  down,  and  of  a  very  low  degree  of  organization,  at  other 
times    they    are  dense    and    firm,    their  tissue    being    plentifully 
supplied  with  vessels.     In  some  cases  reported,  the  vessels  in  the 
adhesions  were  so  large  as  to  give  rise  to  dangerous  hemorrhage 
when  divided. 


382  DISEASES      OF      TVOMEX. 

799.  Contents. — As  I  have  already  stated,  the  contents  of  the 
cysts  varies  much  in  character  ;  in  addition  to  the  fluid  contents 
already  mentioned,  there  have    been  found    hair,  bony  matters, 
remains  of  placenta,  fleshy  substance,  coagulated  blood,  pus,  etc. 
.The  examination  of  the  cyst  contents  with  the  microscope,  is  said 
to  form  a  very  certain  means  of  diagnosis ;  but,  as  it  would  rarely 
prove    available    to    the  general    practitioner,  I  have  omitted  its 
description. 

800.  Symptoms. — In    the   commencement  of   the  disease,   the 
symptoms  are  very  obscure  ;  the   patient   may  feel  a  dull,  heavy 
pain  or  sensation  of  soreness  in  the  ovarian  region,  with  a  sense 
of  weight  in  th<e  pelvis,  and   this  may  cause  her  to  notice  a  slight 
enlargement  in  the  iliac  region.     It  often  happens  that  the  menses 
are  suppressed ;  but  sometimes  this  is  not  the  case.     Sometimes 
the  symptoms  very  much  resemble  pregnancy,  so  much  so,  indeed, 
that  the  patient  may  suppose  herself  pregnant ;  in  addition  to  the 
suppression  of  the  menses,  there  may  be  morning-sickness,  painful 
and  enlarged  breasts,  sometimes,  as  it  is  said,  secreting  milk,  etc. 

801.  So  long  as  the  ovarian  enlargement  does  not  exceed  in 
size  the    space  within   the   pelvis,  it  remains   partially  concealed 
by  the  pelvic  walls,  and  it  may  either  remain  free   and  movable 
in  the  pelvis,  or  form  attachment  to  the  pelvic  contents.     As  the 
cyst  or  cysts  enlarge,  they  arise  into  the  abdominal  cavity,  and  as 
they  change  their  position,  the  uterus  is  drawn  upward  by  means 
of  the  ovarian  ligament,  and  the  vagina  is    elongated.     As  the 
enlargement  continues,  the   dropsical   ovary  occupies   more  and 
more  of  the  abdominal  cavity,  the  intestines  are  pushed  into  the 
inguinal  regions,  arid  the  stomach,  liver,  and  spleen,  together  with 
the  diaphragm,  are  forced  upward  into  the  thorax.     The  symptoms 
at  this  time  are  very  graphically  described  by  Dr.  Burns.     "In 
the  course  of  the  disease,  the  patient  may  have  attacks  of  pain  in 
the  belly,  with  fever,  indicating  inflammation  of  part  of  the  tumor, 
which  may  terminate  in  suppuration,  and  produce  hectic  fever; 
or  the  attack  may  be  more  acute,  causing  vomiting,  tenderness  of 
the  belly,  and  high  fever,  proving  fatal  in  a  short  time ;  or  there 
may  be  severe  pain,  lasting  for  a  shorter  period,  with  or  without 
temporary  exhaustion,  and  these    paroxysms  may  be  frequently 


OVARIAX    DROPSY.  383 

repeated ;  but,  in  many  cases,  these  acute  symptoms  are  absent, 
and  little  distress  is  felt  until  the  tumor  acquires  a  size  so  great  as 
to  obstruct  respiration,  and  cause  a  painful  sense  of  distention. 
By  this  time,  the  constitution  becomes  broken,  and  dropsical 
effusions  are  produced.  Then  the  abdominal  coverings  are 
sometimes  so  tender,  that  they  can  not  bear  pressure ;  arid  the 
emaciated  patient,  worn  out  with  restless  nights,  feverishness, 
want  of  appetite,  pain,  and  dyspnoea,  expires." 

802.  Several  cases  of  ovarian  disease  are  reported  in  which  the 
cyst  was  ruptured  or  gave  way,  and  the  contents  were  discharged 
into  the  peritonial  cavity,  into  the  large  intestines,  the  bladder,  or 
the  vagina,  through  the  fallopian  tube,  or  externally  through  the 
abdominal  Avail.     The  cause  of  this  rupture  has  most  generally 
been  inflammation  terminating  in  suppuration,  though,  in    some 
cases,    it    was    accidental.       Some    of    these    cases    permanently 
recovered    after    the    discharge   of   the    fluid,  while   in   others   it 
produced    a   fatal    result.     The    discharge    of  the    fluid  into   the 
peritoneum  has  been  of   the  most   frequent   occurrence,   and  in 
many  of  these   cases   the  consequent  peritonitis  was   slight,  the 
fluid  was  discharged,  and,  in  some  cases,  the  cyst  obliterated. 

803.  Diagnosis. — We  have  to  distinguish  ovarian  dropsy  from 
pregnancy,   ascites  or  abdominal  dropsy,    tumors   of  the  uterus, 
distended  bladder,  pelvic  abscess,  retention  of  the  menstrual  fluid 
from  imperforate  hymen,  and  hydrometra. 

804.  Pregnancy  may  be  and  has  been  mistaken  for  ovarian 
dropsy,  and  it  is  not  surprising  that  this  should  happen,  when  we 
recollect  that  the  earlier  symptoms  of  ovarian  dropsy  simulate  in 
a  great  degree  those  of  pregnancy.     It  may,  however,  be  easily 
distinguished  by  a  careful  manual  examination,  by  ballottement, 
and  by  the  foetal  movements ;  the  evidence  will  be  positive  if  it 
has  existed  beyond  the  usual  period  of  gestation. 

805.  Ascites  has  been  frequently  mistaken  for  ovarian  dropsy, 
or   ovarian    dropsy  for  ascites.     It    may  be    distinguished    from 
ascites  by  the  defined  form  of  the  enlargement,  by  the  previous 
history,  that  the  tumor  first  appeared  in  one  side,  and  by  its  per- 
manent inclination  to   that  side,  by  its  being  unaltered  in  the 
recumbent  position,  and  by  the  obscure  fluctuation.     Percussion 


384  DISEASES    OF    WOMEX. 

here  is  of  great  value  to  assist  the  diagnosis.  In  ovarian  dropsy 
there  will  be  a  want  of  resonance  over  the  tumor,  in  whatever 
position  the  patient  is  placed,  while  in  ascites  the  dullness  will  be 
in  the  lowest  part  in  all  positions,  while  there  will  be  a  tympanitic 
sound  in  the  highest  level.  In  ascites,  likewise,  the  fluctuation 
will  be  diffused,  if  a  hand  be  applied  to  the  abdomen  at  one  side, 
and  percussed  at  the  other,  the  diffused  character  of  the  fluctua- 
tion will  be  evident.  On  the  contrary  manipulation  discovers  a 
circumscribed  tumor  in  ovarian  dropsy,  in  which  only  the  fluctua- 
tion can  be  observed. 

806.  From  tumor  of  the  uterus,  by  the  absence  of  elasticity  and 
fluctuation,  and  by  a  careful  examination  of  the   uterus  in   the 
manner  heretofore  pointed  out. 

807.  It  is  said  that  a  distended  bladder  has  been  mistaken  for 
ovarian  dropsy,  but  this  could  never  happen  if  the  previous  symp- 
toms  of  urinary  disease  were  taken  into  consideration,  and  the 
catheter  used. 

808.  From  pelvic  abscess  it  may  readily  be  distinguished  by  the 
previous   symptoms,   and   the  present  condition  of  the   patient's 
health.     Ovarian  dropsy  never  producing  the  constitutional  dis- 
turbance, fever,  hot  skin,  loss  of  appetite,  rigors,  and  throbbing 
pain  in  the  part,  that  characterizes  the  other  disease. 

809.  From  retention  of  the  menses,  by  the  result  of  a  vaginal 
examination,  which  will  determine  the  cause  of  the  enlargement. 

810.  From  hydrometra,  by  the  fact  that  in  this  disease  the 
enlargement  is  in  the  median  line,  and  by  its  being  confined  to 
the  uterus,  which  may  be  determined  by  moving  the  uterus  with  a 
finger  introduced  into  the  vagina,  and  by  the  hypogastric  touch. 

811.  The   next  important   point,   after    ascertaining    that   the 
disease  is  ovarian  dropsy,  is  to  ascertain  the  presence  or  absence 
of  adhesions,  more  especially  if  an  operation  is  to  be  performed. 

On  this  point  I  will  quote  from  Dr.  Brown,  he  says : — "  Having 
discovered  ovarian  dropsy,  the  question  of  treatment  will  be 
further  elucidated  by  ascertaining,  if  possible,  whether  the  tumor 
grows  free  from  a  single  pedicle,  or  is  attached  by  adhesions  to 
the  peritoneum  or  to  neighboring  viscera.  To  determine  this,  the 
patient  should  lie  in  the  horizontal  position,  with  the  thighs  flexed, 


OVARIAN    D  R  0  P  S  Y.  385 

so  as  to  relax  the  abdominal  Avail.  •  The  endeavor  to  move  the 
cyst  from  side  to  side  is  first  to  be  made  ;  and,  if  this  can  be 
easily  done,  it  proves  the  absence  of  adhesions  ;  next,  the  hand 
being  placed  firmly  on  the  relaxed  parieties,  if  these  are  readily 
moved  over  the  walls  of  the  cyst,  there  are  no  adhesions,  at  least 
on  the  upper  and  lateral  surfaces.  Lastly,  a  third  argument 
against  the  presence  of  adhesions  is  deducible  when  the  abdominal 
parieties,  which  are  thin  in  this  disease,  can  be  grasped  and 
puckered  up,  and  so  moved  over  the  cyst ;  and  Avhen  they  can  be 
gathered  up  readily  without  raising  the  cyst.  If  these  three  indi- 
cations are  met  with,  we  may  determine  there  are  no  adhesions. 

812.  "Another  plan,  for  which  I  am  indebted  to  my  colleague, 
Dr.  Sibson,  is  based  on  the  extent  to  which  the  contents  of  the 
abdomen  are  forced  downward  during  a  deep  inspiration,  by  the 
descent  of  the  diaphragm.     If  there  be  no  adhesions  in  front,  the 
upper  boundary  of  the  ovarian  tumor  descends  to  the  extent  of  an 
inch  during  a  deep  inspiration  ;  the  space  previously  occupied  by 
the  tumor  being  now  taken  up  by  the  intestines;  consequently,  if 
percussion   be   made  over  the  upper   part   of  the  tumor,  during 
ordinary  respiration,  a  dull  sound  is  elicited ;  but  when  the  patient 
takes   a  deep  inspiration,   an  intestinal   resonance   is  there  per- 
ceptible." 

813.  Treatment. — It   is   a  well    proven  fact  that  no  remedies 
that  can  be  administered  internally  will  have  the  least  effect  in 
decreasing  the  size  of  the  tumor,  nor  in  preventing  its  further 
growth.     Our  only  object  then,  so  far  as  medicine  is  concerned, 
is  to  keep  up  or  restore   the   general  health  of  the  patient,  and 
keep  the  secretions  and  excretions  in  a  normal  condition. 

814.  The  measures  employed  for  the  cure  of  the  disease  when 
this  is  attempted,  and  it  always  should  be,  are  entirely  local  or 
surgical.     Of  these  we  will  consider  separately — 1.   Compression 
and  palpation ;  2.  Tapping  simply;  3.  Tapping  with  compression; 
4.  Tapping  with    injection  of  iodine   into   the  sac;  5.  Artificial 
oviduct,  either  external,  per  vaginam,  or  per  rectum ;  9.  Excision 
of  a  portion  of  the  cyst ;  7.  Extirpation. 

815.  Compression  and  Palpation. — This  method  has  been  tried, 
and,  it  is  reported,  with  success.     Dr.  Hamilton  states  that  after 

25 


386  DISEASES     OF     WOMEN. 

sixteen  years'  trial,  lie  has  succeeded  in  a  number  of  cases  in 
curing  or  retarding  the  disease,  by  compression  of  the  abdomen, 
percussion,  the  use  of  the  warm  bath,  and  a  protracted  course  of 
the  muriate  of  lime,  together  with  the  ordinary  means  for  pro- 
moting the  general  health.  This  mode  of  treatment  should  be 
adopted  in  the  early  stages  of  the  disease,  and  even  if  it  should 
only  retard  the  progress  of  the  disease,  something  will  have  been 
gained.  The  compression  of  the  tumor  should  be  steady  and 
continued,  yet  not  so  severe  as  to  produce  any  inconvenience  to 
the  patient.  Palpation  is  generally  used  with  it;  it  consists  in 
striking  over  the  tumor  gently  for  fifteen  or  twenty  minutes  two 
or  three  times  a  day.  The  main  difficulty  in  applying  compression 
is,  the  difficulty  of  retaining  a  bandage  in  its  position,  especially 
if  the  abdomen  is  enlarged.  A  very  good  contrivance  for  this 
purpose  will,  I  think,  be  found  in  Dr.  Simpson's  plaster  belt. 
"This  consists  of  a  belt  of  lamb's  skin  or  chamois  leather,  eight 
or  ten  inches  deep,  and  shaped  and  sewed  so  to  carefully  fit  the 
loins  and  lower  part  of  the  abdomen  of  the  patient,  like  a  common 
abdominal  bandage,  and  embossed  in  front  so  as  to  contain  and 
include,  as  in  a  bowl  or  cup,  the  protuberant  portion  of  the  tumor. 
To  fix  this  belt,  its  interior  is  spread  with  a  plaster  composed  of 
one  part  of  adhesive  to  two  parts  of  soap  plaster ;  they  require 
to  be  removed  and  renewed  every  four  or  six  weeks."  This  plaster 
belt  will  not  only  furnish  the  requisite  degree  of  compression,  but 
it  will  support  the  tumor  and  abdomen,  and  thus  relieve  the  disa- 
greeable sensations  attendant  on  the  weight  of  the  tumor. 

816.  Tapping. — Tapping  is  hardly,  if  ever  resorted  to  as  a  means 
of  cure,  but  as  a  palliative  measure  giving  temporary  relief  from 
the  distension.  Though  tapping  is  not  expected  to  produce  a  cure, 
yet  many  cases  are  on  record  where  it  was  followed  by  permanent 
relief,  no  reaccumulation  taking  place.  Mr.  Brown,  however, 
thinks  that  these  were  cases  of  cystic  disease  of  the  broad  liga- 
ment, or  fallopian  sacs,  and  not  ovarian  cysts.  By  the  most 
of  authors  it  is  advised  to  defer  tapping  as  long  as  possible,  from 
the  fact  that  the  fluid  reac  cumulates  faster  than  it  did  before,  and 
that  it  is  always  altered  in  character  for  the  worse,  and  that  the 
operation  itself  is  not  unattended  with  danger. 


OVA HI AX     DROPSY.  387 

817.  Two    methods    of    performing    paraeentesis    are    recom- 
mended, either  of  which  may  be  adopted.     In  the  first,  and  that 
most  commonly  adopted,  the  patient  is  placed  in  a  sitting  posture 
on  a  chair  or  on  the  edge  of  the  bed,  and  a  broad  bandage  placed 
around  the  abdomen  and  crossed  behind  the  back,  each  end  being 
held  and  tightened  by  an  assistant,  as  the  fluid  is  evacuated.     The 
operation  is  usually  performed   in   the  linen   alba,  about  half  way 
between    the   umbilicus    and    pubes,    at   this   point   a    hole    is   cut 
through  the  bandage  through  Avhich  to  make  the  incision.     The 
surgeon  then  makes  an  incision,  about  three-fourths  of  an  inch 
long,   through    the    integuments,    and    then    passes    through    this 
opening  a  large  shed  diamond-pointed  trocar  and  cannula  into  the 
cavity  of  the  cyst.     Instead  of  making  a  first  incision  with  the 
lancet,  some  surgeons  use  nothing  but  the  trocar.    The  trocar  being 
withdrawn,  the  fluid  passes  through  the  cannula  and  is  received  in 
a  proper  vessel.     Until  the  cyst  is  emptied,  steady  compression 
should  be  kept  up  by  the  assistants,  and,  if  possible,  the  entire 
fluid  contained  in  the  cyst  should  be  evacuated.     As  soon  as  the 
fluid  is  drawn  off,  the  wound  should  be  closed  with  adhesive  plas- 
ter,  the  bandage  around  the  abdomen  fastened,   and  the  patient 
placed  in  bed. 

818.  The  other  method   recommended  is  to  have  the  patient 
placed  in  the  horizontal  position,  lying  near  the  edge  of  the  bed, 
on  the  side  that  is  affected,  and  with  the  tumor  projecting  over 
the  edge  of  the  bed.     The  trocar  is  then  introduced  as  already 
described,   either  in  the  course  of  the  linea  alba,  or  linea  semi- 
lunaris  ;  if  the  cyst  is  punctured  in  the  semi-lunar  line,  care  will 
have  to  be  taken  to  avoid  the  epigastric  artery  and  any  enlarged 
veins    which   may  be   present.      Toward  the  termination  of  the 
operation    the    most    complete    evacuation    of   the   fluid    may  be 
secured,  by  turning  the  patient  upon  her  breast,  so  as  to  make 
the  puncture  the  most  dependent  part  of  the  cyst.     The  advan- 
tages  to  be   derived  from  this  position  are,  that  the  abdominal 
bandage  can  be  dispensed  with,  to  the  great  relief  of  the  patient, 
to  the  assistants,  and  to  the  operator:  that  the  contents  of  the 
dropsical    cyst    or    cysts    can   be    more    easily    and    completely 
evacuated  ;  that  there  is  not  near  so  much  liability  of  air  enter- 


388  DISEASES     OF     WOMEX. 

ing  the  cavity  ;  and  that  this  position  prevents  faintness,  which 
so  often  occurs  when  the  patient  is  in  the  erect  posture. 

819.  Tapping  with    Pressure. —  After    tapping,  the    abdomen 
should  be  compressed,  as  affording  an  additional  probability  of 
cure,  as  well  as  a  matter  of  precaution  when  the  origin  of  the 
cyst  is  obscure.     Compression,  however,  to  be  beneficial,  should 
be  steady  and   continued,  though   not  so   severe  as   to  give  the 
patient  any  pain  or  uneasiness.     The  directions  given  for  pressure 
heretofore,  will  apply  to  compression  after  tapping.     The  benefits 
to  be  derived  from  pressure  after  tapping,   are:  to  prevent   the 
re-filling  of  the  cyst,  partly  by  keeping  its  walls  in  contact,  and 
partly  by  compressing  the  vessels  supplying  it ;  it  is  also  supposed 
to  act  as  a  curative  measure,  by  causing  absorption  of  the   cyst 
structure,  in  the  same  manner  that  other  tumors  are  dispersed  by 
pressure.     Some  cases    are    reported,    in   which    these    measures 
have    been  followed  by  a  permanent  cure;  these  cases,  however, 
are  supposed  to  have  been  unilocular  cysts ;  in  other  cases,  it  has 
retarded  the  progress  of  the  disease,  and  in  others,  no  beneficial 
effect  was  perceived. 

820.  Tapping,  and  Injection  of  Iodine. — Of  late  years,  it  has 
been  attempted  to  produce  adhesion  of  the  cyst-walls  after  evacu- 
ating the  fluid,  by  means  of  irritating  substances  thrown  into  its 
cavity,  in  the  same  manner  that  adhesions  are  produced  between 
the  walls  of  the  tunica  vaginalis  in  hydrocele.    For  this  purpose,  a 
solution  of  the  Sulphate  of  Zinc,  Iodide  of  Potassium,  Tincture  of 
Iodine,  etc.,  have  been  used,  but  none  but  the  last  mentioned  agent 
are  now  used.     The  benefit  to  be  derived  from  this  practice  may 
be  seen  in  the  following  conclusions  arrived  at  by  Dr.  Simpson, 
from  his  own  experience  in  its  use,  and  from  the  reports  of  others. 

821.  1.  "  In  none  of  the  cases  of  ovarian  dropsy  treated  with 
iodine  injections  after  tapping,  has  he  yet  seen  any  considerable 
amount  of  local  pain  follow  the  injection,  with  but  one  exception ; 
in  most  instances,  no  pain  at  all  is  felt;  and  in  none  has  con- 
stitutional irritation  or  fever  ensued.     In  the  one  exceptional  case, 
considerable  local  irritation  followed;  and  the  pulse  rose  to  110; 
but  the  same  phenomena  occurred  in  the  same  patient  after  pre- 
vious tappings,  without  iodine  being  used. 


OVARIAN    DROPSY.  389 

822.  2.   "While  the  practice  seems  thus  so  far  safe  in  itself, 
it  has  by  no  means  proved  as  successful  as  in  hydrocele,  in  pre- 
venting a  reaccumulation  of  the   dropsical  fluid;   for,  in   several 
instances,   the  effusion   into   the   sac  seems  to   have  gone   on   as 
rapidly  as  after  a  simple  tapping,  without  iodine  injection. 

823.  3.   "  But,  in  tAvo  or  three  of  the  cases,  the  iodine  injection 
appears  to  have  quite  arrested,  for  the  time  heirig,  the  progress 
of  the  disease,  and   to  have  produced  obliteration   of  the  tapped 
cyst,  as  there  is  no  sign  of  any  reaccumulation,  though  several 
months  have  now  elapsed  since  the  date  of  the  operation. 

824.  Lastly.    "  Accumulated  experience    will  he  required    to 
point  out  more  precisely  the  special  varieties  of  ovarian  dropsy 
most  likely  to  henefit  from  iodine  injections,  the  proper  times  of 
operating,    the  quantities    to    be   injected,  and  other   co-relative 
points.     Perhaps  the  want  of  success  in  some  cases,  has  arisen 
from  an  insufficient  quantity  of  iodine  being  used,  and  from  the 
whole  interior  of  the  cyst  not  being  touched  by  it.     The  greatest 
advantage  would,  of  course,  be  expected  from  it  in  the  rare  form  of 
unilocular  ovari.an  cyst.   In  the  common  compound  cyst,  the  largest 
and  most  preponderating  cyst  is  usually  alone  opened  in  paracen- 
tesis ;  and  though  it  were  obliterated,  it  would  not  necessarily  pre- 
vent  some  of  the  other  smaller  cysts  from  afterward  enlarging 
and  developing  into  the  usual  aggravated  form  of  the  disease." 

825.  Dr.    Simpson    recommends    the    undiluted    Tincture    of 
Iodine  for  the  injection,   of  which  from  two  to  three  ounces  are 
used  for  an  injection;  in  some  cases,  he  allows  a  portion  of  the 
fluid  to  escape,  while  in  others,  the  whole   is  retained.     Iodine 
injected   into  an  ovarian   cyst,   has  never  been   detected  in  the 
urine,  thus  showing  that  the  cyst-wall  has  no  absorbing  power ; 
while,  if  the  tincture  of  iodine  is  placed  in  contact  with  the  nor- 
mal tissues,  as  in  injecting  the  sac  of  a  hydrocele,  it  is  absorbed, 
and  may  be  detected  in  the  urine. 

826.  Artificial  Oviduct. — It  has  been  proposed  to  effect  a  cure 
of  ovarian  dropsy,  by  forming  a  fistulous  opening,  through  which 
the  fluid  of  the  cyst  may  be  discharged,  and  from  the  degree  of 
irritation  produced  by  the  constant  discharge  and  altered  character 
of  the  secretion,  an  eventual  adhesion  of  the  walls  of  the   cyst 


390  DISEASES    OF    WOMEN. 

would  take  place.  The  operation  has  been  frequently  performed 
in  Paris  and  in  England,  as  it  is  reported,  with  a  considerable 
degree  of  success.  This  method  of  treatment  was  proposed  by 
the  French  surgeon,  Le  Dran,  but  the  best  description  of  it  is  by 
Mr.  Baker  Brown,  case  49.  "  Having  administered  chloroform, 
I  placed  the  patient  in  the  horizontal  posture,  near  the  edge  of  the 
bed,  and  made  an  incision  two  inches  in  length,  about  half  way 
between  the  umbilicus  and  the  anterior  and  superior  spine  of  the 
ilium,  dissecting  carefully  down  to  the  peritoneum.  I  next  made 
a  second  (shorter)  incision  at  right  angles  with  the  first,  extend- 
ing from  its  lower  termination  inward  to  the  median  line.  The 
flap  thus  formed  was  dissected  back,  exposing  the  peritoneum 
with  the  subjacent  whitish  cyst  appearing  through  it.  Introduc- 
ing a  large-sized  trocar  at  the  angle  at  which  the  two  incisions 
met,  I  withdrew  nine  pints  of  fluid,  containing  pus  and  flocculent 
matter ;  and  before  removing  the  cannula,  divided  the  peritoneum 
in  the  line  of  the  longer  incision  ;  and  having  reflected  it  on  each 
side,  stitched  the  cyst  to  the  tendon  of  the  external  oblique 
muscle,  taking  care  not  to  include  any  portions  of  muscle,  or  of 
peritoneum.  The  next  step  was  to  remove  the  cannula,  and  with 
a  pair  of  scissors  to  divide  the  cyst  midway  between  the  sutures ; 
a  piece  of  lint  dipped  in  oil  was  then  inserted,  and  secured  by 
strapping ;  lastly,  the  external  wound  was  partially  closed  at  its 
extremities  by  sutures."  After  the  artificial  opening  is  formed 
in  the  manner  described,  it  is  kept  from  closing  up,  either  by  the 
daily  introduction  of  tents,  or  as  Le  Dran  first  proposed,  by  the 
insertion  of  a  very  large  but  short  cannula. 

827.  The  character  of  the  discharge  will  be  very  much  changed 
by  the  contact  of  air  with  the  cyst- wall,  and,  when  the  operation 
succeeds,  it  will  gradually  decrease  in  quantity  until  the  cyst  is 
occluded,  when  the  artificial  opening  may  be  allowed  to  close.     If 
the  discharge  from  the  cyst  becomes  very  offensive,  an  injection  of 
dilute  Liquor  Sodae  Chlorinata  has  been  used  with  advantage. 

828.  In    the   cases  reported,  where    this    operation   was   per- 
formed, some  were  entirely  successful,  in  others  it  was  but  pallia- 
tive, a  fistula  being  left,  the  ovarian  sac  not  having  closed,  and 
in  others   it   terminated  fatally.     I  have  no  means  of  knowing 


O  Y  A  H  I  A  X    I)  1!  0  P  S  Y  .  391 

definitely  the  percentage  of  cures  resulting  from  it,  as  it  has  not 
been  as  extensively  performed  ;;s  other  operations  for  the  same 
disease,  still  from  the  cases  reported  I  think  it  worthy  of  a  trial. 

829.  The  artificial  opening  has  likewise  been  made  from  the 
cyst  through  the  vagina,  and  also  through  the  rectum,  and,  when 
the  cyst  is  low  down  in  the  recto-vaginal  space,  the  vaginal  open 
ing  would  probably  be  preferable. 

830.  Excision  of  a  portion  of  the  cyst. — This  operation  consists 
in  making  a  small  incision  through  the  abdominal  wall,  evacuating 
the   contents   of  the  cyst,   and  then   drawing  it  out  through  the 
opening,  excising  a  larger  or  smaller  portion  of  it,  returning  it  to 
the  abdomen  and  closing  the  external  wound.     The  object  to  be 
attained  by  the  operation  is,  first,  the  evacuation  of  the  fluid,  and, 
second,    an  artificial   communication   between    the    cyst    and    the 
peritoneal  cavity,   the   fluid    that    is    effused    by   the   cyst   being 
reiibsorbed  by  the  peritoneum.     The  operation  is  predicated  upon 
the  fact  that  in  cases  where  cysts  were  accidently  ruptured,  their 
contents  being  discharged  into  the  peritoneal  cavity,  the  fluid  was 
absorbed  by  the  peritoneum,  and  the  patient  thus  cured.     It  has 
been  recommended  by  some  authors  to  make  an  incision  not  more 
than  an  inch  in  length,  either  in  the  linca  alba,  or  linea  semi- 
lunaris,  through  which  the  cyst  may  be  drawn  out  and  excised. 
Others,  however,  among  whom  is  Mr.  Baker  Brown,  consider  that 
the  patient  runs  no  more  risk  from  an  incision  two  or  three  inches 
in  length,   than  from  one   an  inch,   and   that  this  large  incision 
enables  the  surgeon  to  determine  the  vascularity  of  the  cyst,  and 
the  character  of  its  adhesions,  to  avoid  severing  any  blood-vessels 
in  the  excision,  or  to  tie  any  that  might  be  divided  by  the  knife. 

831.  In  regard  to   the   success   of  this  operation   Mr.  Baker 
Brown  says  : — "  The  excision  of  a  portion  of  the  cyst  is  an  opera- 
tion more  free  from  danger  than  complete  extirpation,  and  less 
tedious  in  its  results  than  the  formation  of  an  artificial  oviduct. 
But  it  has  a  limited  application.     The  conditions  likely  to  favor 
its  success  are :    The  cyst  unilocular,  its  walls  thin,  and  possessed 
of  little   vascularity,   very  few   or  no   adhesions,    the  fluid  only 
slightly  albuminous,  and  of  a  light  specific  gravity.     When  these 
favorable  circumstances  coexist  with  unimpaired  general  health, 


392  DISEASES     OF     WOMEN. 

or  very  little  ailment,  then  only  should  this  operation  be  per- 
formed. If  pressure  had  been  tried  without  success,  or  was 
interdicted  by  the  existence  of  prolapsus  uteri,  or  by  any  other 
objection,  an  additional  reason  to  try  this  operation  would  exist. 
Now,  by  preferring  the  longer  incision,  and,  being  prepared  tc 
extirpate  the  whole  cyst  if  necessary,  the  surgeon  will  be  able  to 
explore  the  parts  to  ascertain  what  operation  is  most  eligible. 
For  instance,  if  the  walls  of  the  cyst  are  found  thicker  and  more 
vascular  than  was  expected,  it  will  be  safer  to  proceed  to  extir- 
pate the  entire  cyst,  after  tying  its  predicle,  than  to  run  the  risk 
of  profuse  hemorrhage  by  cutting  out  a  portion.  Or,  if  the  cyst 
is  found  to  be  thin,  unilocular,  unattached,  and  unvascular,  and 
the  fluid  thin,  then  the  plan  of  excising  a  portion  may  be  adopted 
with  reasonable  prospect  of  success." 

832.  Extirpation. — Extirpation,  or  the  entire  removal  of  the 
diseased  mass,  is  the  last  resort  of  the  surgeon  when  other 
measures  fail,  or  in  cases  in  which  they  are  not  applicable.  There 
is  no  need  of  disguising  the  fact,  that  it  is  a  most  serious  and 
dangerous  operation,  and  that  it  has  often  been  the  means  of 
shortening  the  lives  of  patients,  who  might  otherwise  have  lived 
for  months,  and  perhaps  years.  Yet  in  other  cases  it  has  been 
the  means  of  restoring  numbers  to  health,  who  otherwise  would 
have  shortly  succumbed  to  the  disease.  The  question  here  arises, 
is  ovariotomy  justifiable  ?  This  question  can  be  best  answered  by 
each  practitioner  after  examining  the  evidence  on  both  sides. 
This  evidence  I  propose  briefly  to  give. 

883.  First — Ovarian  dropsy  in  many  cases  is  essentially  a 
chronic  disease ;  many  women  living  for  years  who  are  subjects 
of  the  disease,  and  even  enjoy  a  comparative  degree  of  health. 
Thus,  "  Sabatier  examined  the  bodies  of  several  women  who  had 
carried  these  encysted  tumors  during  half  a  century,  without 
alarming  derangement  of  health.  Dr.  Ashwell  states  that  cases 
have  fallen  under  his  observation,  in  which  women  have  become 
pregnant,  and  have  been  many  times  safely  delivered,  notwith- 
standing a  dropsy  of  the  ovary;  and  others,  when  the  tumor, 
although  of  considerable  size,  had  existed  for  many  years  without 
tapping,  or  any  other  than  mere  palliative  treatment.  Again,  we 


OYARIAX     DROPSY.  393 

have  numerous  cases  reported  where  the  patients  were  frequently 
tapped,  and  yet  lived  for  many  years. 

834.  Notwithstanding  that  some  women  have   lived  for  many 
years   with  ovarian  dropsy,  in  a  very  large  majority  of  cases  the 
disease  has  ultimately  proved  fatal ;  and  in  at  least  a  majority  of 
cases,    the   disease   has   proved   fatal   in  from   one   to   five   years. 
Again,  in  those  cases  in  which  ovariotomy  has  been  proposed  as  a 
remedy,  it  is  almost  certain  not  only  that   the  disease  will   prove 
fatal,  but  that  in  a  comparatively  short  time. 

835.  In  regard  to  the  success  of  the  operation,  it  is  as  great  as 
in  other  operations  Avhich  are  sanctioned  by  the  entire  profession. 
Thus,  in  68  cases,  collected   and  tabulated  by  Dr.  Churchill,  41 
recovered  and  25  died,  or  one  in  about  two  and  a-half ;  these  cases 
embraced  those  of  every  variety,  with  and  without  adhesions,  in 
which  the  operation  could  not  be  completed,  and  8  cases  in  which 
there  was  an  error  in  the  diagnosis  ;  the  table  must,  therefore,  at 
least,  be   considered  as  a  fair  statement  of  the  success  attending 
the    operation.      Dr.  Atlee,   of   Philadelphia,   has  tabulated  172 
legitimate  cases  of  ovariotomy ;  of  these  123  recovered,  and  49 
died,  or  one  in  3  25-49,  or  28  21-43  deaths  in  100  cases.     Mr.  S. 
Lee  has  collected  114  cases  of   ovariotomy,    of  which  74   cases 
recovered,  and  40  died,  or  nearly  one  in  three.     Now,  according 
to  Dr.  Simpson,  the  results  of  amputations  in  the  Paris  hospitals 
from  1836  to  1841,  were— 

Out  of  201  amputations  of  the  thigh,  126  died,  or  6    in  every  10 
«      192  "  "       leg,     106  died,  or  5£  "      "      10 

"       91  "  "       arm       41  died,  or  4J  "      "      10 

Thus,  it  will  be  seen  that  ovariotomy  has  been  as  successful  as 
operations  that  are  considered  fully  justifiable,  and  that  are  per- 
formed every  day. 

836.  Does  ovariotomy,  however,  effect  a  perfect  cure  of  the 
disease,  so  as  to  secure   the    patient  against  its   return  ?     This 
question  may  be  answered  in  the  affirmative.     Dr.  Simpson  con- 
siders that  the  pathological  nature  of  multilocular  disease  of  the 
ovary  is  such  that  it  has  no  tendency  to  recur  after  its  complete 
.removal.     From  the   character   of  its  morbid   structure,  and  its 


394  DISEASES     OF     WOMEX. 

clinical  history,  it  is  certain  that  it  presents  no  liability  to  spring 
up  again,  like  malignant  or  tubercular  disease  in  the  same  locality. 
or  in  distant  and  in  different  organs  of  the  body.  The  other 
ovary  might  be  partially  affected,  and  if  so,  might  require  removal 
along  with  the  first,  a  step  which,  at  the  time,  would  probably  not 
add  much  to  the  absolute  danger  of  the  operation,  seeing  the 
abdomen  was  once  opened."  Contrast  this  with  other  opera- 
tions. '•  The  surgeon  amputates  a  limb,  or  excises  a  tumor  for 
some  form  of  carcinomatous  disease,  hazarding  more  or  less  the 
life  of  his  patient,  for  the  temporary  removal  of  a  diseased  action 
"which  is  almost  perfectly  certain  to  recur.  He  ties  the  subclavian 
for  aneurism ;  but  is  it  not  a  disease  which  is  very  liable  to  coexist 
in  different  vessels  at  the  same  time,  or  to  form  consecutively  in 
different  parts ;  and  if  the  patient  escapes  the  great  and  imminent 
dangers  of  the  operation,  has  he  any  surety  against  its  reappear- 
ance elsewhere?  You  amputate  the  thigh  to  get  rid  of  a 
scrofulous  or  tubercular  knee-joint.  But  in  how  many  cases  is 
local  tubercular  disease  the  mere  result  of  a  general  diathesis, 
that  ere  long  will  betray  itself  in  some  other  part  or  organ." 

837.  From  the  dangerous  character  of  the  operation,  and  the 
importance    of    having    direct    and    explicit    rules    to    guide   the 
surgeon,  it  would  be  supposed  that  we  would  have  many  minute 
descriptions  of  it  in  the  various  treatises  on  the  subject.     Yet  so 
far    as    my    reading    has    extended,    and    it   has   been    tolerably 
extensive,  I  have  seen  but  one  description  that  I  would  be  willing 
to  put  into  the  hands  of  the  student  or  practitioner  as  a  guide.    It 
is  a  well-known  fact,  that  in  such  operations  as  this,  success  does 
not  depend  upon  the  skill  with  which  the  operator  uses  the  knife, 
but  upon  his  attention  to  the  small  matters  preparatory  for  the 
operation,  during  it,  and  in  the  after  treatment.     The  only  author 
that  gives  this  necessary  description  is  Mr.  Baker  Brown,  and  I 
can  not  do  better  for  my  readers  than  to  give  his  description. 

838.  Conditions  rendering  the  operation  of  ovariotomy  justifi- 
able.— 1.  "  The  surgeon  should  be  satisfied,  by  most  careful  and 
repeated  examination,  that  the  tumor  is  ovarian ;  and  those  with 
whom  he  may  consult  should  take  equal  pains  to  form  an  unbiased 
opinion. 


OVARIAX     DROPSY.  395 

2.  "  That  the  tumor  is  increasing,  and  that  the  disease  will  bo 
most  likely  to  progress  to  a  fatal  issue  if  allowed  to  take  its  course. 

3.  "  That  such   of   the   different    modes   of   treatment  already 
described   as  appear  to   be   suitable    to    the    case,   excepting  the 
excision  of  a  portion  of  the  cyst,  have  been  fairly  tried  without 
lasting  benefit. 

4.  "  That  the  tumor  is  not  cancerous. 

5.  "  That  the  patient  is  not  so  reduced,  in  her  general  health 
and   vigor,  as    to    render  her  an  unfit    subject    for  a  formidable 
operation. 

6.  "  That  there  is  no  evidence  of  the  existence  of  adhesions. 

7.  "  That  the  fluid  is  not  highly  albuminous. 

839.  Preparations  for  the  operation. — "  As  all  important 
operations  are  liable  to  fail  from  the  neglect  of  little  things,  both 
in  preparatory  proceedings  and  in  the  operation  itself,  the 
following  suggestions,  all  of  which  are  really  of  moment,  may  be 
useful  to  those  who  are  about  to  operate  for  the  first  time. 

1.  "  If  the  weather  be  cold,  the  patient  should  have,  ready  to 
•wear,  a  flannel  waistcoat,   and    a   pair   of   flannel    drawers ;    the 
•waistcoat  should  be  put  on  before  the  operation. 

2.  "  She  should  have  a  warm  bath  the  night  before  the  opera- 
tion, to  cleanse   the   skin,  and  thereby  insure    free    perspiration 
after  the  operation. 

3.  "  The  bowels  should  be  opened  by  a  dose  of  ox-gall  or  castor 
oil  and  an  enema,  on  the  morning  of  the  operation  day. 

4.  "  A  hot-water  bottle  should  be  prepared  for  her  feet. 

5.  "  There    should    be   a  thermometer    in    the    room,   and   the 
temperature  should  be  kept  systematically  at  not  lower  than  66 
degrees,  nor  higher  than  70  degrees.     A  kettle   should   also  be 
boiling  on  the  fire,  so  as  to  make  it  possible  to  insure  a  degree  of 
moisture  in  the  air  by  the   steam.     This   is   especially  requisite 
•when  the  wind  is  in  the  east,  or  the  weather  hot  and  dry. 

6.  "If  the  operation  take  place  on  the  bed  which  the  patient  is 
afterward  to  occupy,  the  lower  part  of  it  should  be  prepared  and 
guarded  by  a  mackintosh- sheet  and  an  old  blanket,  which  can  be 
afterward  removed.     There  should  be  a  hassock  or  stool  for  the 
feet  to  rest  upon ;  the  feet  and  legs  should  be  clothed  in  warm 


DISEASES     OF     WOMEX. 

stockings,  and  the  hands  and  arms  enveloped  in  a  warm  flannel 
gown. 

7.  "  As    the    patient   will    have    chloroform    administered,    she 
should  not  take  any  food  for  some  hours  previous  to  the  operation, 
and,  to  avoid  sickness  afterward,  a   supply  of  ice  should  be  pre- 
pared for  her  to  suck  for  two  or  three  hours  before  the  operation; 
this  is  of  much  consequence. 

8.  "  There  should  be  plenty  of  hot  water  in  the  room,  in  which, 
in    cold    weather,   both    the    operator    and    his    assistants    should 
immerse  their  hands  before  touching  the  patient ;  and  there  should 
be  from  three  to  six  basins  of  warm  water  ready  for  immersing 
sponges,  or  warming  flannels,  etc. 

9.  "  The   duties   of  each   assistant    should  be  clearly  assigned 
and  understood  before  entering  the  room,  so  as  to  avoid  confusion, 
and  also  to  save  time,  an  important  point  when  the  peritoneum  is 
exposed. 

10.  "  Four  or  six  large  needles  should  be  got  ready,  armed 
with  the  best  twine,  well-waxed,  for  the  interrupted  suture,  and 
one  large  needle  to  carry  the  double  ligature  (also  of  twine,  not 
of  silk)  for  the   pedicle.      Several   smaller  ligatures,  for  blood- 
vessels, should  also  be  ready,  and  a  flannel  bandage  to  go  round 
the  abdomen  after  the  operation  is  completed;  also  a  supply  of 
lint  and  a  few  adhesive  straps. 

11.  Instruments. — "  One  or  two  scalpels,  a  pair  of  scissors,  a 
pair  of  vulsellum-forceps,  a  pair  of  good  common  forceps,  tenacu- 
lum,  trocar,  and  cannula  of  large  size,  together  with  the  needles 
and  ligatures,  should  be  ready  on  a  tray. 

Lastly — "  As  much  will  depend  upon  the  after-treatment,  it  will 
be  well  to  arrange  beforehand  that  the  operator,  or  some  other 
competent  surgeon,  should  remain  with  the  patient  all  night ; 
indeed,  she  should  not  be  left  for  more  than  two  hours  at  a  time, 
for  the  first  three  or  four  days. 

840.  Mode  of  operating. — "  The  patient  being  placed  conve- 
niently on  her  back,  and  brought  under  the  influence  of  chloro- 
form, an  exploratory  incision,  from  two  to  three  inches  in  length, 
should  first  be  made  in  the  linea  alba.  Having  divided  the  peri- 
toneum, and  reached  the  cyst,  two  or  more  fingers  should  be 


OVAKIAX    Duopsr.  397 

passed  over  its  surface  to  ascertain  if  adhesions  exist;  if  these 
are  slight  and  recent,  they  should,  if  possible,  be  broken  down  by 
the  fingers,  or,  if  they  are  few  and  small  in  diameter,  so  as  to  bear 
division,  they  may  first  be  tied,  to  guard  against  hemorrhage,  and 
afterward  divided,  but  if  they  are  spread  out  to  a  considerable 
breadth,  it  is  better  to  desist  from  any  further  procedure  with  a 
view  to  extirpation.  If,  on  the  contrary,  there  are  no  adhesions, 
or  only  such  as  can  be  easily  broken,  the  incision  should  be 
enlarged  to  four  inches,  or  more  if  necessary.  The  next  step  is 
to  tap  the  cyst  or  cysts  with  a  proper  trocar  and  cannula,  and  in 
the  evacuation  of  the  fluid  to  take  care  that  none  of  it  escapes 
into  the  cavity  of  the  abdomen ;  then,  if  there  be  only  one  cyst, 
and  that  not  thick  nor  vascular,  a  portion  of  it  only  may  be 
excised  in  the  manner  heretofore  described.  If  the  cyst,  however, 
should  be  found  to  be  thick,  or  vascular,  or  multilocular,  it  will  be 
the  safest  procedure  to  have  recourse  immediately  to  complete 
extirpation  in  the  following  manner  :  The  pedicle  of  the  tumor  is 
to  be  taken  in  the  left  hand,  and  gently  drawn  outward  from  the 
pelvic  cavity,  an  assistant  carefully  keeping  back,  by  warm  flan- 
nels, the  bowels  and  omentum.  The  course  of  the  blood-vessels 
in  the  pedicle  should  now  be  carefully  observed,  so  that  the  latter 
can  be  safely  punctured  by  a  scalpel  or  bistoury,  and  through  the 
opening  thus  made  an  aneurismal-needle,  carrying  a  double 
ligature  of  the  strongest  twine,  be  passed  and  firmly  tied  on  each 
side  of  the  pedicle.  Mr.  Wilson  advises  that,  instead  of  passing  a 
ligature  round  the  pedicle,  each  vessel  should  be  tied  separately  ; 
this  some  regard  as  an  important  improvement.  This  ligature 
should  be  passed  as  near  to  the  tumor  as  possible,  so  that,  by  the 
entire  length  of  the  pedicle  being  preserved,  the  ligatured  end 
may  be  kept  external  to  the  abdominal  cavity,  together  with  the 
ligature,  as  recommended  by  Messrs.  Duffin  and  Erichsen ;  this 
done,  the  tumor  should  be  removed  by  dividing  the  pedicle  half 
an  inch  from  the  ligature,  which  should  be  given  to  an  assistant, 
and  held  at  the  inferior  end  of  the  opening.  The  operator  then 
closes  the  wound — and  this,  I  need  hardly  say,  should  be  done,  as 
in  all  operations  exposing  the  peritoneum,  as  soon  as  possible — 
by  introducing  deep  sutures,  about  an  inch  from  the  incised  edges, 


DISEASES     OF     WOMEN*. 

through  the  parieties  of  the  abdomen,  taking  care  to  avoid  the 
peritoneum  ;  these  sutures  should  be  about  half  an  inch  apart. 
The  edges  of  the  wound  should  then  be  more  carefully  brought 
together  by  superficial  interrupted  sutures  occupying  the  inter- 
mediate space  between  the  deep  ones.  It  now  only  remains 
to  prevent  the  end  of  the  pedicle  and  the  ligatures  from  returning 
into  the  abdomen  ;  for  this  purpose,  a  common  director,  with  its 
convex  surface  turned  toward  the  abdomen,  should  be  passed 
through  the  ligatures,  so  as  to  be  firmly  held  bv  them  at  right 

O  O  •/  •/ 

angles  to  the  wound.     The  ends  of  the  ligatures  should  now  be 

c  ~ 

secured  to  the  abdomen  by  adhesive  plaster,  and  the  wound 
dressed  with  common  water-dressing ;  this  done,  the  abdomen 
must  be  supported  by  a  many-tailed  fiannel  bandage,  comfortably 
tight,  the  patient  be  placed  in  bed,  and  warmth  applied  to  the 
extremities.  Two  grains  of  opium  are  to  be  at  once  given,  and 
one  grain  repeated  every  three  or  four  hours  until  pain  is  allayed. 
Ice,  milk,  barley-water,  or  weak  broths  should  constitute  the  diet 
for  the  first  twenty-four  hours  ;  afterwards,  stronger  animal  broth 
may  be  allowed,  and  wine,  if  the  condition  of  the  patient  admit  of 
it.  It  is  better,  if  possible,  that  the  bowels  should  be  confined  for 
four  or  five  days  after  the  operation ;  the  bladder  should  also  be 
emptied  every  six  hours  by  the  catheter.  The  temperature  of  the 
room  should  be  carefully  maintained  for  the  first  week  after  the 
operation. 

841.  "  I  have  not  enjoined  the  use  of  any  particular  length  of 
incision  ;  for  this  matter  must,  I  am  of  opinion,  be  regulated  by 
the  special  circumstances  of  each  case,  the  rule  on  the  surgeon's 
part  being  to  extract  the  cyst  with  the  least  danger  to  the  patient, 
and  through  the  smallest  practicable  incision,  without  incurring 
the  risk  of  a  failure  in   the  operation.     A  small  incision  of  an 
exploratory  nature  should  be  the  first ;  if  the  operation  be  pro- 
ceeded with,  it  must  be  enlarged  sufficiently  to  admit  the  extrac- 
tion of  the  apparent  cyst,  and  further  increase  will  be  very  easy, 
if,  by  its  peculiarly  compound  nature,  its  position  or  relations, 
or  other  circumstances,  demand  it. 

842.  "It  is  desirable,  when  the  diseased  ovarian  mass  of  one 
side  is  removed,  and  before  the  abdominal  incision  is  closed,  to 


OVARIAN      DKOPSY. 

look  at  the  condition  of  the  other  ovary,  which  not  uncommonly 
is  also  diseased,  and,  when  such  is  the  case,  it  may  be  at  once 
removed. 

843.  "The  dangers  to  he  apprehended  after  ovariotomy  are: 
1.  The  shock  of  the  operation  ;  2.  Hemorrhage ;  3.  Acute  in- 
flammation— peritonitis ;  4.  Inflammation  of  a  low  or  typhoid 
character. 

1.  "Now  that  we  have  the  benefit  of  chloroform,  the  dangers 
from  the  shock  of  the   operation    are  greatly  lessened  ;    but   in 
some   of  high   nervous   susceptibility   and    debililated    frame    the 
shock  may  be  fatal  or  severely  felt,  even  though  chloroform  has 
been  employed  during  the  surgical  proceedings,  and  the  patient 
has  not  regained  consciousness  until  they  are  over,  and  the  wound 
dressed.     Like  similar  cases  from  other  operations  these  demand 
the  use  of  stimulants  and  other  means  of  support. 

2.  "  Hemorrhage  is  unfortunately  not  so  uncommon,  the  source 
of  it  being  mostly  from  the  cut  pedicle  or  supporting  base  of  the 
tumor.     It  will  be  seen,  however,  that  in  one  of  my  cases  the  fatal 
bleeding  had  its  source  in  the  divided  vessels  of  an  adhesion  ;  and 
it  is  this  event  which  has  induced  me  to  recommend  the  tying  of 
any  divided  bands  of  adhesion  where  they  have  any  thickness,  and 
do  not  readily  break  down  before  the  finger.     The  tying  of  the 
Btalk  as  I  advise,  will,  I  think,  generally  provide  against  hemorr- 
hage from  it,  care  being  taken  to  leave  the  pedicle  out  of  the 
wound.      Hemorrhage   may  kill  either  by  the  exhaustion  imme- 
diately induced,  or  by  the  peritonitis  it  kindles. 

3.  "Acute  peritonitis,  in  a  more  or  less  severe  form,  is  a  most 
frequent  occurrence  after  extirpation ;  its  origin  we  may  trace  to 
the  natural  effort  of  the  system  to  close  the  wounds  made  in  the 
tissues  in   the   operation  by   effusion   of  plastic   lymph.     Every 
precaution  is  to  be  taken  against  the  advance  of  this  inflammation, 
and  its  treatment  must  be  based  on  the  ordinary  principles. 

4.  "Peritonitis  of  a  low  or  typhoid  type  appears  later  than  the 
preceding  conditions,  and  is  seen  when  any  of  the  cut  tissues  put 
on  an  unhealthy  appearance,   and  when  probably  some  morbid 
excretions  get  into  the  blood.     Here,  again,  no  special  directions 


400  DISEASES     OF     WOMEN. 

are  necessary,  since  the  ordinary  principles  of  treatment  are  those 
to  be  pursued. 

844.  "  It  will  sometimes  happen  that  unlooked-for  conditions 
present  themselves  after  the  abdomen  is  laid  open,  and  complicate 
or   even  render    impossible    the    operation ;    among    such    is    an 
unusual  vascularity  of  the  cyst,  and  consequent  danger  of  fatal 
hemorrhage.     Examples   of  this   condition    have   occurred    suffi- 
ciently aggravated   to  deter  from  completing   the  operation ;    in 
such  cases   the   surgeon   must   rely  on   his   own  judgment.     No 
precise  rules  can  be  laid  down,  but  I  imagine  the  vascularity  of 
the  sac  need   rarely  arrest   the  operation.     Unexpected   attach- 
ments of  the  cyst  posteriorly  to  the  intestines,  or  to  other  viscera, 
of  such  a  nature  that  it  would  be  dangerous  to  destroy  them,  will 
operate  more  frequently  in  discountenancing  extirpation.     Cancer, 
indeed,  may  not  be  discovered  until  after  the  operation  is  com- 
menced, and  be  so  situated  as  at  once  to  stop  it. 

845.  "  Now,  in  all  these  cases,  excepting  cancer,  where  the  steps 
previous  to  the  drawing  forth  of  the  cyst  have  been  proceeded 
with,  and  we  are  compelled  to  cease  from  attempt  at  extirpation, 
the  excision  of  a  portion  of  the  cyst  is  a  mode  of  treatment  still 
available." 

846.  I  have  thus  endeavored  to  present  to  my  readers  a  brief, 
yet  complete  history  of  ovarian  dropsy,  and  the  various  means 
which  have  been  employed  for  its  relief,  and  in  all  that  has  been 
stated  on  the  subject,  I  have  been  careful  to  embody  nothing  but 
what  has  been  fully  proven  by  careful  observation.     Especial  care 
has  been  taken  in  the  description  of  the  treatment  so  far  as  space 
would  permit,  and  as  I  hope,  so  minutely,  that  the  reader  will 
have  no  difficulty  in  applying  the  different  measures  recommended 
in  practice :  and  I  might  conclude  this  chapter  in  the  words  of 
Dr.  Blundell :  "  In  the  present  ill  success  of  our  practice,  all  these 
operations  are  well   worth  your   consideration;    and  if  you   can 
bring  one   of  them   to   such  perfection  as  to  cure  some  of  the 
unhappy  individuals  who  now  fall  victims  to  the  disease,  you  will, 
indeed,  be  conferring  an  invaluable  good  on  the  fairest  and  least 
offending  part  of  our  species." 


TITMOKS    OF    THE   OVARY.  401 

TUMORS  OF  THE  OVARY. 

847.  Of  those  morbid  growths  which  have  their  origin  from  the 
ovary,  we  have  two  varieties,  the  non-malignant  or  fibrous,  and 
the  malignant  or  cancerous.     The  consideration  of  neither  of  these 
varieties  is  of  practical  importance,  as  the  treatment  of  them  is 
merely  palliative,  and  conducted  on  general  principles,  the  only 
point  of  interest  being  their  diagnosis  from  other  diseases. 

848.  Fibroid  tumors  of  the  ovary. — Fibroid  tumors  of  the  ovary 
are  very  similar  to   the  same  growths   in  the  uterus;  in  fact,  in 
many  cases  it  is  very  hard  to  determine  whether  the  growth  had 
its  origin  from  the  uterus  beneath  the  peritoneum  and  had  become 
detached,  or  whether  it  had  its  origin  from  the  ovary.     They  may 
have  their  origin  within  the  substance  of  the  ovary,  distending 
that   organ   nearly   equally  in   every   direction,  or  they   may   be 
situated  immediately  beneath  the  peritoneal  covering,  and  project 
from  one  side  of  it.     These  tumors  are  generally  very  small,  not 
larger  than  a  pea  or  patridge's  egg.     Cruvelheir  says,  however, 
that  they  vary  from  a  few  drachms   to  thirty  or  forty  pounds ; 
these   large  tumors   are   thought  by   most  authors   to   be   always 
malignant.      The  growth  of  fibroid  tumors  of  the  ovary  is  always 
very  slowr,  and  they  rarely  give   rise  to  symptoms  of  much  im- 
portance. 

849.  Cancer  of  the  ovary. — This  disease  is  of  much  more  fre- 
quent  occurrence   than   the   growths   last   described,  indeed,  the 
ovary  stands  second  in  the  list  of  organs  attacked  by  cancer.     It 
is  more  frequent  than  cancer  of  the  breast,  and  nearly  as  frequent 
as  the  same  disease  of  the  uterus.     Cancer  of  the  ovary  is  the 
raost  formidable  affection  to  which  the  ovary  is  liable,  as  it  proves 
certainly  fatal,  and  is  not  amenable  to  the  treatment  adopted  for 
cancer  in  other  parts  of  the  body. 

850.  Three  varieties  of  ovarian  cancer  may  be  distinguished, 
the  areolar,  scirrhous,  and  encephaloid  cancer.     The  first  of  these 
has  already  been  described  under  the  head  of  ovarian  dropsy ;  it 
consists  of  numerous  fibrous  sacs,  generally  containing  a  glutinous 
viscid  matter.     The  second  variety  or  scirrhus,  presents  the  same 
characteristics  that  it  does  in  other  organs ;  it  is  of  variable  size, 
uneven  and  tuberose,   and  when   cut    into    it   creaks    under   the 

26 


402  DISEASES     OF    WOMEN. 

scalpel,  and  shows  a  whitish  firm  structure,  intersected  by  strong 
membranous  divisions.  The  third  variety  or  encephaloid  cancer, 
is  rarely  met  with ;  it  varies  considerably  in  structure ;  generally 
it  consists  of  a  fibrous  sheath,  intersected  with  fibrous  septa,  within 
this  fibrous  structure  we  find  effused  the  cerebriform  matter. 
The  density  of  the  growth  varies  much,  sometimes  it  is  almost  as 
compact  as  scirrhus,  while  at  others  it  gives  a  distinct  fluctuation. 

851.  Symptoms. — In  the  early  stages  of  the  disease,  the  symp- 
toms are  very  obscure,  and  it  is  generally  only  when  it  has  so 
increased  in  size  as  to  produce   mechanical  inconvenience,  that 
complaint  is  made ;    and  at  this  time  it  is  very  difficult,  if  not 
impossible,  to  distinguish  it  from  other  lesions  of  these  organs. 

852.  Scirrhous  cancer  is  very  slow  in  its  growth  as  a  general 
rule,  and  it  may  exist  for  years  without  producing  any  dangerous 
symptoms.     Encephaloid,  on  the  other  hand,  has  generally  a  rapid 
growth,  and  it  may  become  of  enormous  size  in  a  few  months : 
the  symptoms  presented  by  this  variety  are  always  much  better 
marked.     According  to   M.  Colombat :    "When   the   disease  ap- 
proaches a  fatal  termination,  the  tumor,  which  becomes  irregular, 
and   more    and   more    enlarged,   softens    in    certain  points ;    the 
shooting  pain,  which  has  been  compared  to  the  pricking  of  needles, 
becomes  more  and  more  severe,  and  extends  to  the  neighboring 
parts,  to  the  uterus,  vulva,  loins,  and  thigh  corresponding  to  the 
diseased  side ;  hemorrhages  and  discharges  of  an  ichorous  char- 
acter and  a  disgusting  odor,  escapes  from  the  vagina,  which,  by 
extension  of  the  degeneration,  often  exhibits  fungous  vegetations, 
of  a  granulated  and  livid  reddish  appearance.     The  pains  extend 
by  sympathy  to  the  knees,  legs,  breast  and  shoulders ;  the  stomach, 
particularly,  is  affected,  so  that  digestion  is  imperfectly  performed, 
and  the  patient,  who  acquires  an  extreme  disgust  for  food,  is  also 
troubled  with  nausea  and  vomiting,  together  with  obstinate  con- 
stipation of  the  bowels ;  lastly,  a  state  of  insomnia,  amounting  to 
almost  sleeplessness,  a  permanent  condition  of  hystericism,  rapid 
emaciation,  and  continued  fever,  are  harbingers  of  her  approaching 
end,  the  inevitable  termination  of  this  scene  of  pain." 

853.  Where  but  one  ovary  is  affected  by  the  disease,  menstrua- 
tion may  not  be  disturbed ;    cases   are  even  reported   in  which 


TUMORS  OF  THE  OVARY.  403 

conception  occurred,  and  in  which  gestation  went  on  the  usual 
time,  the  female  being  delivered  of  a  healthy  child,  though  the 
malignant  growth  Avas  of  considerable  size.  Cancer  of  the  ovaries 
frequently  occurs  with  ovarian  dropsy,  and  in  many  cases  it  has 
existed  with  it  without  being  detected  until  ovariotomy  was  being 
performed. 

854.  Diagnosis. — In  the  early  periods  of  the  disease,  it  can 
not  be  distinguished  from  non-malignant  growths  of  the   ovary  ; 
but  after  it  becomes  fully  developed,  the  severity  of  the  symptoms 
will  generally  be  sufficient  to  make  the  distinction.     The  diagnosis 
of  the  situation  of  the   disease   may  be  eifected  in   the   manner 
already    pointed    out,   when    describing    fibroid    tumors    of    the 
uterus,  etc. 

855.  Treatment. — Active  medication  in  this  disease  would  be 
exceedingly  injurious  ;  no  measures  can  be  resorted  to  with  the 
faintest  prospect  of   effecting   a   cure.      The  treatment  pursued 
should  be  directed  to  sustaining  the  general  health  of  the  patient, 
and  to  palliate  as  far  as  possible  her  sufferings.     Dr.   Churchill 
recommends,  both  in  cancer  and  fibroid  tumors  of  the  ovary,  when 
they  have  enlarged  so  as  to  produce  compression  in  the  pelvis,  to 
push  them  above  the  brim,  and  in  this  manner  relieve  the  mechan- 
ical symptoms. 


404  DISEASES     OF     WOMEX 


CHAPTER     XIII 


PUERPERAL  FEVER. 

856.  Puerperal  or  child-bed  fever  is  one  of  the  most  dangerous 
diseases  to  which  the  parturient  female  is  liable,  and,  though  it  is 
not  of  unfrequent  occurrence,  both  sporadically  and  as  an  epidemic, 
yet  we  find  that  scarcely  any  two  writers  on  the  subject  agree  in 
regard  to  the  pathology  of  the  disease. .    This  discrepancy  in  the 
opinions  of  writers  upon  the  subject  has  doubtless  arisen  from  the 
fact,   that    in   the   different    epidemics   of  the  disease,   it   varied 
greatly,  not  only  in  the  phenomena  which  it  presented  during  life, 
but  also  in  the  lesions  which  were  found  upon  post-mortem  exami- 
nations.    Still,  from  reading  the  different  treatises  on  the  disease, 
notwithstanding  the  difference  in  the  opinions  of  the  writers,  the 
mind   will  be  forcibly  impressed  with  the  fact,  that  the  disease 
itself  was  the   same,  though,  from  local  causes  or  other  circum- 
stances, its  manifestations  were  different.     The  opposite  plans  of 
treatment  followed  by  different  writers,  do  not  appear  to   have 
been  founded  on  any  actual  difference  in  the  disease,  but  upon  a 
pre-conceived  theory  of  its  character. 

857.  It  is   not  worth  while,  in  the  short  space  that  I  have  to 
devote  to  the  description  of  the  disease,  to  enter  into  a  considera- 
tion of  the  many  theories  advanced  in  regard  to  its  nature,  as  I 
think  that  each  of  my  readers  will  be  able  to  obtain   a  correct 
knowledge  of  it  from  the  chapter  on  its  pathological  anatomy. 

858.  Causes. — The  predisposing  causes  of  puerperal  fever  are 
Buch   as   depress   the   vital    powers   of  the   system,   and   lead   to 
unhealthy  action  in  general.     Among  these  might  be  named,  low 
and  ill-ventilated  abodes,  deficient  food,  intemperate  habits,  anxiety 
and  a  desponding  state  of  the   mind,  etc.      These  causes   have 
reference,  however,  principally  to  sporadic   cases ;  for,  when  the 
disease   prevails  as  an  epidemic,  nearly  every  puerperal  female 
within  the   affected    district   suffers  from    an    attack.     In    these 


1'  U  E  R  P  E  R  A  L     F  E  V  E  R  .  40  -5 

epidemic  visitations,  the  disease  attacks  alike  the  rich,  in  their 
well-provided  lying-in  apartments,  with  all  the  attention  that 
could  be  desired,  with  every  comfort  and  convenience,  and  the 
poor,  in  the  hovel  or  the  cellar,  without  any  convenience  or 
attention. 

859.  The  exciting   causes    of   the   disease,    when    it    does   not 

O  ' 

prevail  epidemically,  are,  an  exposure  to  cold  or  to  dampness, 
imprudence  in  rising  from  the  bed  at  too  early  a  period,  in  taking 
improper  food,  stimulants,  etc.  Retention  of  a  portion  of  the 
placenta  is  also  given  as  a  cause  of  the  disease,  the  suppression 
of  some  accustomed  excretion,  etc.  Of  the  exciting  causes  of 
epidemic  puerperal  fever  we  know  but  little.  It  has  been  ascribed 
by  some  authors  to  the  state  of  the  atmosphere ;  by  others  to  a 
contagion  carried  from  one  parturient  female  to  another  by  the 
physician ;  and  by  still  another  it  is  considered  to  be  an  erysipe- 
latous  inflammation  which  may  be  communicated  either  by  the 
peculiar  constitution  of  the  atmosphere,  or  by  contact  with  the 
morbid  product  of  the  disease,  carried  either  upon  the  hands  or 
clothes  of  the  practitioner. 

860.  This  brings  us  to  the  consideration  of  the  contagious  or 
non-contagious  character   of   the   disease,  about   which   so   much 
has  been  said  and  written,   and  upon  which    some   of  our  most 
eminent  medical  practitioners  are  at  variance.     Among  those  who 
affirm  the  contagious  character  of  the  disease,  might  be  mentioned 
Drs.  Ramsbotham,  Denman,  Burns,  Hamilton,   Blundell,  Gooch, 
Lee,  and  others ;    and    an  equally  eminent   list  of   obstetricians 
might   be    named    who    oppose    it.      Without    entering    into    the 
discussion  of  this  matter,  however,  I  will  give  the   views  of  Dr. 
Meigs  on  this  subject,  in  which  I  place  the  most  implicit  con- 
fidence, from  the  known  accuracy  of  his   observations,  and  from 
his  extensive  experience.     He  says,  "  I  have  practiced  midwifery 
for  many  long  years.     I  have  attended  some  thousands  of  women 
in   labor,   and  passed  through   repeated   epidemics   of   child-bed 
fever,    both   in    town    and    hospital.     After    all    this   experience, 
however,  I  do  not,  upon  careful  reflection  and  self-examination, 
find  the  least  reason  to  suppose   that  I  have  ever  conveyed  the 
disease  from  place  to  place  in  any  single  instance.     Yet  for  many 


400  DISEASES    OF    WOMEN. 

years  I  carefully  considered  whether  such  a  transfer  by  a  third 
person  might  be  possible,  and  carefully  read  the  statements  of 
various  authors  to  that  effect.  In  the  course  of  my  professional 
life,  I  have  made  many  microscopic  researches  of  child-bed  fever, 
but  never  did  suspend  my  ministry  as  accoucheur  on  that  account. 
Still  I  certainly  never  was  the  medium  of  its  transmission.  I  have, 
in  numerous  instances,  gone  from  the  bedside  of  women  dying  of 
child-bed  fever,  whether  sporadic  or  the  most  malignant  degree  of 
epidemic,  without  making  my  patients  sick.  I  have  also  endeavored 
to  assist  my  brethren  when  they  had  such  cases  and  I  had  none. 
In  a  series  of  labors,  468  in  number,  and  beginning  with  No.  1,  1 
find  that  Nos.  18  and  19  were  affected,  and  that  No.  18  died  with 
child-bed  fever ;  No.  31  was  sick,  but  recovered ;  Nos.  195  and 
259  were  sick,  but  recovered ;  but  291  died,  as  did  also  293.  Nos. 
332,  339,  435,  444,  were  attacked,  and  recovered.  The  above 
13  cases  were  in  468  labors,  of  which  3  died  and  10  recovered. 
Now,  if  I  was  the  medium  of  contagion  for  any  one  of  that  series 
of  468  confinements,  why  did  I  poison  them  in  the  ratio  and  order 
above  set  forth  ;  and  why  did  I  not  communicate  the  disease  in 
more  than  13  out  of  468  cases?  What  became  of  my  nebula 
from  31  to  195 ;  to  259,  and  between  291  and  435,  and  so  to  the 
end,  or  468  ?  Such  a  table  is  far  more  easily  explained  by 
regarding  the  falling-out  of  the  cases  as  coincidences  and  acci- 
dents, than  as  material  causations,  through  a  private  pestilence." 

861.  The  believers  in  the  non-contagious  character  of  the  dis- 
ease, do  not,  however,  ignore  the  fact  that  suitable  attention  and 
care  on  the  part  of  the  practitioner  should  be  paid  to  cleanliness, 
etc.,  as  there  can  be  no  doubt  of  the  virulent  character  of  the  morbid 
matter  produced  by  the  disease,  and  that  if  brought  in  contact 
with  tissues  that  will  absorb  it,  it  will  reproduce  the  disease. 
Thus,  when  attending  cases  of  puerperal  fever,  the  following  rules 
should  be  strictly  observed.  1.  That  after  examining  any  case 
of  this  disease,  the  hands  should  be  carefully  washed  with  soap 
and  water,  the  nails  cleaned,  and  kept  pared  short.  And  after 
making  an  autopsy  on  any  dead  body,  his  hands  should  be  washed 
•with  a  solution  of  chloride  of  lime  until  the  cadaveric  odor  had 
entirely  disappeared  from  them,  and  it  would  be  better  to  com- 


PUERPERAL     FEVER.  407 

pletely  change  his  dress.  2.  That  when  it  is  possible,  the 
practitioner  should  visit  first  his  other  patients,  arid  afterward 
the  cases  of  puerperal  fever,  and  that  if  this  can  not  he  done,  he 
should  first  have  his  clothes  well  aired,  or  change  before  visiting 
other  parturient  cases. 

862.  From  the  facts  before  us,  we  have  good  reason  to  believe 
that  puerperal  fever  arises  either  from  the  absorption  of  a  morbid 
material  generated  by  a  local  inflammation,   the  primary  disease 
being  local ;  or  that,  in   epidemics  of  the  disease,  the  circulating 
fluids  are  first  affected,  the  primary  disease  being  general,  while 
the  local   inflammation   is   secondary,  or   the    effect   of  a  morbid 
condition  of  the  blood.     In  the  first  instance,  the  disease  usually 
commences  as  a  metritis,  though  sometimes  as  an  inflammation  of 
the  peritoneum,    or  the  uterine  appendages,  the  first   symptoms 
presented  being  those  of   acute  local   inflammation ;    but  as   the 
disease    advances,   the    constitutional    affection    may    become    so 
marked  that  it  will  present  all  the  characteristics  of  the  malignant 
typhoid  fever,  so  often  met  with  in  epidemics  ;  this  is  the  sporadic 
form  of  the  disease.     In  epidemics  of  the  disease,  in  the  most  of 
instances,  the  affection  of  the  blood,  as  before  stated,  is  the  prim- 
ary affection,  which  has  a  tendency  to  localize  itself  in  the  uterus 
and  its  appendages,  owing  to  their  great  susceptibility  to  disease 
after  parturition ;  even  in  this  case  the  secondary  local  inflamma- 
tion has  always  a  tendency  to  aggravate  the  general  disease. 

863.  I  do  not  consider  that  it  is  necessary  for  practical  purposes 
to  try  to  point  out  the  distinctions  between  the  several  seats  of 
the    local   inflammation,    further    than    to   give    the    pathological 
changes  in  the  different  structures ;  all  that  we  wish  to  determine 
in    practice   is,    whether    puerperal    fever    exists,    and    its    form, 
whether  merely   inflammatory,   the  constitutional  effect   or  fever 
being  caused  by  the  local  inflammation,  or  whether  it  is  typhoid, 
the  blood  crasis  being  affected  ;  in  other  words,  whether  the  fever 
is  the  result  of  the  natural  reaction  of  the  system,  or  whether  it 
is  the  result  of  a  septic  condition  of  the  blood. 

864.  Pathological  Anatomy. — In  considering  the  post-mortem 
appearances  presented  by  puerperal  fever,  we  have  to  look :  1. 
To  the  lesions  of  the  uterus.     2.  Of  the  veins  and  lymphatics  of 


408  DISEASES    OF    WOMEN. 

the  uterus.  3.  Of  the  peritoneum.  4.  Of  the  uterine  append- 
ages, the  ovaries  and  fallopian  tubes.  5.  Of  other  organs  inci- 
dentally involved  by  the  puerperal  process.  In  reference  to  the 
comparative  frequency  of  these  lesions  in  different  organs,  the 
following  tables  will  be  found  interesting  : 

Inflammatory  Lesions  in  371  Fatal  Cases  of  Puerperal  Fever. 

(FROM  DUGES.) 

Peritonitis  was  observed  in 266  cases. 

Metritis,  or  pus  in  veins,  etc. 200      " 

Ovaritis  ••  48      " 

Gastritis  and  Enteritis 4      " 

Pleuritis  •  •  40      " 

Pericarditis 6      " 

Arachnitis  1      " 

Pus  in  Muscles  or  Joints 8      " 

Inflammatory  Lesions  in  222  Fatal  Cases  of  Puerperal  Fever. 

(FROM    TONNELLE.) 

Peritonitis  was  observed  in 193  cases, 

Metritis  and  Ovaritis 197      " 

Pus  in  the  Uterine  Veins,  or  Lymphatics 112      "• 

Gastritis  and  Enteritis 6      " 

Pleuritis 43      " 

Pneumonia 21      " 

Pericarditis  and  Hydro-Pericarditis 1      " 

Pus  in  Liver,  Pancreas,  Muscles,  etc. 19      " 

Pus  in  Joints 12      " 

i 
865.    These  tables  show  that  in  a  large  majority  of  cases,  the 

disease  locates  itself  in  the  uterus  or  peritoneum,  or  in  other  words, 
that  the  local  disease  is  a  metritis  or  peritonitis ;  that  the  ovaries 
are  not  near  so  liable  to  be  affected,  and  the  general  nature  of  the 
disease,  as  seen  in  the  frequent  affection  of  other  portions  of  the 
system.  In  the  separate  consideration  of  each  of  these  morbid 
processes,  I  will  depend  principally  on  the  description  of  Prof. 
Rokitansky,  who  has  probably  examined  more  cases  of  this  disease 
than  any  other  writer. 


i>  u  K  u  r  E  E  A  L   r  E  v  E  K  .  409 

800.  Puerperal  Endometritis. —  Prof.  Rokitunsky  considers 
this  affection  to  be  invariably  an  exudative  process,  varying,  how- 
ever, greatly,  as  it  regards  the  plasticity  of  the  inflammatory 
exudation;  in  some  cases  of  pure  inflammation,  the  exudation 
being  organizable  like  that  in  croup,  while  in  others,  it  is  a  putrid 
inorganizable  matter.  He  says: 

867.  "  In  certain   cases,  we  find  the  internal  surface  of   the 
uterus  lined  by  a  yellowish  or  greenish  dense  exudation,  of  greater 
or  less  thickness  and  extent;  either  in  small  patches,  or  investing 
the  entire  uterus,  and  either   firm    or  loosely   agglutinated,  and 
occasionally   partially   or   entirely    detached  from    the   subjacent 
tissues,   so    as    to    appear    corrugated   or  plicated.     The   uterine 
mucous  membrane  under  this  coating  is  found  reddened,  tumefied, 
and  slightly  softened ;  the  free  parts  are  discolored,  and  invested 
with  a  dirty  reddish  or  brownish  secretion,  and  with  remnants  of 
the    deciduous    membrane.     The   exudation  generally   interpene- 
trates largely  the  exposed  raw  tissue  of  the  placental  portion  of 
the  uterus,  and  causes  it  to  assume  a  peculiar  ulcerated  appear- 
ance.    This  is  the  form  of  inflammation  usually  seen  in  sporadic 
•cases  of  the  disease,  in  those  marked  by  high  inflammatory  symp- 
toms; the  next  described,  is  the  condition  met  with  in  epidemics 
of  the  disease,  or  where  it  assumes  a  typhoid  character. 

868.  "  In  other  cases,  the  exuded  matter  is  a  gelatinous,  puru- 
lent dirty  yellow,  loose  and  easily  detached  layer,  beneath  which, 
the  internal  stratum  of  uterine  tissue  appears  spongy,  infiltrated, 
soft,  and  may  be  easily  detached  in  the  shape  of  a  dirty  yellowish 
red,  or  partly  greenish  and  brownish  pulp.     The  internal  surface 
of  the  uterus  presents,  in  addition  to  the  exudation,  a  glutinous 
secretion  of  a  similar  tinge. 

869.  "  Again,  the  internal  surface  of  the  uterus  may  not  pre- 
sent a  trace  of  coagulable  lymph,  but  be  invested  by  a  purulent 
sanious  and  very  discolored  exudation,  beneath  which,  we  find  the 
uterine  mucous  membrane  infiltrated,  in  more  or  less  extensive  or 
circumscribed  patches,  with  a  similar  product;   and  it  may  either 
be  easily  removed  in  the  shape  of  a  thin  and  much  discolored 
pulp,  or  it  has  already  become  detached,  and  is  mixed  up  with  the 
^contents  of  the  uterus,  in  the  shape  of  a  friable  discolored  floe- 


410  DISEASES     OF     WOMEN. 

culi.  In  the  place  of  the  destroyed  tissue,  we  occasionally  dis- 
cover the  products  of  a  reactive  process,  in  the  shape  of  a  more 
or  less  consistent  sero-purulent  secondary  exudation." 

870.  "  Again,    the   internal   layer  of    uterine  tissue    may  be 
covered  with  a  thin  opaque  or  more  dense,  pale-green  or  brown- 
ish, or  dark-chocolate  or  coffee-colored  product,  beneath  which,  it 
is  converted  to  a  greater  or  less  depth,  into  a  loose,  infiltrated, 
fetid  pulp,  of  a  similar  tint.     This  condition,  which  differs  from 
ordinary  sphacelus,  has  been  termed  putrescence  of  the  uterus." 

871.  These  various  morbid  appearances    correctly    mark    the 
violence   of  the  general  disease,  the  plasticity  of   the  exudation 
depending  entirely  upon  the  condition  of  the  blood;  thus,  when 
the  disease  presents  a  simple  inflammatory  character,  the  exudate 
will  be  coagulable  lymph,  but  as  it  assumes  the  typhus  character, 
the  exudation  gradually  loses  this  character,  until  it  presents  the 
unorganized  dark  fetid  product. 

872.  According   as  the  disease  attacks   the  uterus   sooner   or 
later    after  parturition,   the   uterus   will  be   found  more   or  less 
enlarged,  its  involution  being  stopped  when  attacked  by  inflamma- 
tion ;  and  it  will  be  more  or  less  relaxed,  softened,  and  infiltrated. 
Thus,  if    the  inflammation   commences   two  or  three   days  after 
delivery,  it  will  be  as  large  as  an  infant's  head;  but  if  several 
days  have  elapsed,  it  may  not  be  more  than  two,  three,  or  four 
times  its  natural  size. 

873.  Inflammation   of    the     Veins   and    Lymphatics    of  the 
Uterus. —  "Uterine    phlebitis    is    generally   a   primary   affection, 
originating  in  the  open  mouths  of  the  veins  at  the  insertion  of  the 
placenta,  and  caused  as  well  by  their  laceration,  as  by  contact 
with  the  external  atmosphere,  with  the  traumatic  secretion  of  the 
part,  and  with  the  product  of  exudation  on  the  internal  surface  of 
the  uterus.     It  is  either  confined  to  a  small  portion  of  the  veins, 
or  it  spreads  over  the  greater  part  of  the   veins   of  the   uterus 
belonging  to  the  spermatic  or  uterine  system  of  vessels.     In  the 
latter  case,  a  secondary  inflammation  of  the  trunk  of  the  sper- 
matic vein,  brought  on  by  coagulation  of  the  blood,  may,  on  the 
one  hand,  extend  through  the  vena  cava  to  the  right  auricle,  or  on 
the  other,  along  the  iliac  and  crural  veins,  to  the  cutaneous  vein* 


PUERPERAL     FEVER.  411 

of  the  lower  extremity;   in  this  case,  the  symptoms  of  phlegmasia 
dolens  are  induced." 

874.  "If  incisions  be  made  in  various  directions  from  the  point 
of  insertion  of  the  placenta,  to  the  lateral  parieties  of  the  uterus 
and  broad  ligaments,  a  large  number  of  veins  become  apparent, 
which  are  dilated  and  varicose,  and  filled  with  yellow  or  greenish- 
yellow  viscid  pus,  or  even  with   chocolate-colored  sanies.     Their 
orifices  at  the  placental  portion  of  the  uterus,  are  either  closed  up 
by  loose  pale  coagula,  or  they  are  covered  over  with  an  exudation 
which  attaches  itself   to   the   spongy  tissue  of  the  raw  surface, 
or,  lastly,  they  are  exposed  so  that  their  contents  exude  on  the 
application   of  a    slight   pressure.     The    coats   of  the   veins    are 
relaxed  and  pale,  the  lining  membrane  is  opaque,  and  discolored 
by  the  contents  of  the  vessels,  and  after  a  protracted  duration  of 
the  disease,  it  appears  tumefied,  thickened,  partially  gangrenous 
and  ichorous.     The  tissue  surrounding  the  veins,  and  especially 
the  cellular  tissue  at  the  lateral  portions  of  the  uterus,  is  infil- 
trated with  a  yellow  gelatinous  or  purulent  matter,  which  is  much 
discolored  if  the  contents  of  the  veins  are  ichorous;  the  tissue  is 
relaxed,   soft,  friable,    and    lacerablc.     At  different  points   there 
are   abscesses   of  greater  or  less    dimensions,   which    not  unfre- 
quently  burst   internally,  and    discharge   their  contents  into  the 
uterus." 

875.  Inflammation  of  the  uterine  lymphatics  is  of  much  less 
frequent   occurrence  than  the   same  disease  of  the  veins,  and  is 
generally    complicated    with    the    latter.      When    it    occurs,    the 
lymphatics  on  each  side  of  the  uterus,  in  the  broad  ligaments,  and 
passing  up  with  the  spermatic  veins,  may  be  observed  dilated  and 
varicose,  the  coats  of  the  vessels  thickened  and  firm,  and  of  a  pale 
color,  and  they  contain  a  yellow,  yellowish-green,  purulent  fluid. 
Sometimes  they  are  so  much  distended  as  to  present  the  appear- 
ance  of  small   abscesses ;  by  the   distension   of  the  lymphatics, 
their  course  may  be  traced  from  the  uterus  to  the  neighboring 
lymphatic  glands,  which  are  sometimes  similarly  affected. 

876.  Though  inflammation  of  the  veins  and  lymphatics  may 
occur  as  the  sole  and  primary  disease,  yet  in  a  very  large  majority 
of  cases  it  is  found  in  connection  with  metritis. 


412  DISEASES     OF     WOMEN. 

877.  Inflammation  of  the  Peritoneum. — We  have  already  seen 
that  peritonitis  occurs  in  about  six  out  of  every  seven  cases  of 
puerperal  fever,  and  yet   it   rarely  exists  as  a  separate  primary 
affection.     It  is   most  frequently  found  occurring  with  metritis, 
with    metrophlebitis,   ovaritis,   and    inflammation    of    the    uterine 
lymphatics. 

878.  "Puerperal  peritonitis  is  not  unfrequently  limited  to  the 
peritoneal  covering  of  the   uterus   and  its   appendages,  when  it 
presents  more  or  less  redness,  with  more  or  less  distinct  conges- 
tion and  a  thin  partial  exudation,  or  a  more  dense  and  extensive 
layer  of  a  viscid  and  consistent  or  loose  and  fluid  secretion." 

879.  "  We  not  only  find  the  peritoneal  covering  of  the  internal 
sexual  organs  attacked  in  this  way,  but  also  the  peritoneum  of 
the  entire  hypogastric  abdominal  region.     The  disease  may  even 
spread  over  the  whole  parietal  and  intestinal  peritoneal  lamina ; 
the  symptoms,  however,  predominating  on  the  peritoneum  of  the 
internal  sexual  and  adjoining  organs.     The  entire  peritoneum  is 
often    uniformly  involved    in   the   disease,  not  only  without  any 
predominance  of  the  symptoms  in  the  sexual   organs,  but  some- 
times even  with  an  apparent  subordination  of  these  symptoms." 

880.  The  products  of  these  processes  vary  very  much ;  they 
may  be  firm,  yellowish-gray  concretions,  loose,  yellowish,  mem- 
branous, grumous,  gelatinous,  or  fibrinous  coagula,  which  glue  the 
intestines  to  one  another,  or  to  the  parieties  of  the  abdomen,  or 
they  may  be  yellow  and  greenish -yellow,  thin,  sero-purulent  or 
thick  purulent,  dirty  green  and  brownish,  red,  hemorrhagic,  thin, 
opaque,  sanious  effusions,  the   result  of  septic   peritonitis.     The 
product  is  sometimes  very  limited  in   amount,  and  may  merely 
present  a  thin  covering  of  the  internal  sexual  organs,  or  a  few 
membranous  or  fibrinous  flocculi  of  coagulable  lymph,  scattered 
through  the  abdominal  cavity ;  but  in  the  case  of  universal  perito- 
nitis, it  is  generally  extremely  copious,  whatever  the  particular 
variety  of  the  product." 

880.  Puerperal  peritonitis,  no  doubt,  in  a  majority  of  cases, 
arises  from  an  extension  of  the  inflammation  of  the  uterus  or  its 
appendages  by  a  contiguity  of  tissue,  though  it  may  occur  as  the 
primary  disease.  Prof.  Rokitansky  thinks  that  the  disease  is 


I-  r  E  It  I'  K  R  A  L     F  E  V  E  R .  41 3 

often,  and  even  generally,  the  result  of  a  primary  condition  of  the 
blood  of  the  female,  which  predisposes  to  exudative  processes,  and 
is  totally  distinct  from  the  physiological  tendencies  of  the  blood 
during  pregnancy. 

881.  Puerperal  Ovaritis. — Inflammation  of  the  ovaries  is  no 
of  near  so  frequent   occurrence  in  puerperal  fever  as  the  lesions 
heretofore  described;    it  is  generally  observed  as  a  complication 
of  inflammation  of  the  other  parts  heretofore  described,  though  it 
may  exist  as  the  primary  disease. 

882.  We  have   seen,  when  describing   simple   inflammation   of 
the  ovary,  that  the  disease  was  most  frequently  confined  to  the 
Graafian  follicles,  but  in  the  puerperal  inflammation  it   involves 
the  entire  structure  of  the  ovary.     The  puerperal  process  in  the 
ovary  resembles   that   described   as   occurring  in  the  uterus,  the 
plasticity  of  the  inflammatory  product  bearing  a  direct  relation  to 
the  condition  of  the  circulating  fluids. 

888.  The  ovary  is  always  more  or  less  enlarged,  of  the  size  of 
a  hen's  or  goose's  egg,  and  presenting  the  various  changes  which 
have  been  heretofore  mentioned.  Thus,  "  the  deposit  may  be  serous, 
or  fibrinous  and  fusible,  filling  the  tissues,  and  causing  the  follicles 

/  O  f  O 

to  present  an  opaque  appearance ;  or  it  may  be  a  yellowish,  or 
reddish,  gelatinous,  viscid  product,  which  is  deposited  in  the  stroma 
in  large  quantities;  the  latter  being  at  the  same  time  friable  or 
semi-fluid,  the  follicles  tumid,  their  coats  swollen,  and  their  con- 
tents opaque  and  flocculent;  or,  it  may  present  various  discolor- 
ations,  and  be  at  the  same  time  collapsed  and  pulpy,  its  tissue 
distended  by  a  dirty  yellowish-brown,  brownish-green,  chocolate- 
colored  fluid,  or  converted  into  a  fetid  pulp." 

884.  Puerperal  inflammation  of  the  ovary  sometimes  terminates 
in  suppuration  and  the  formation  of  an  abscess.  It  may  com- 
mence at  separate  points,  which  gradually  coalesce,  or  it  may  be 
set  up  in  a  single  spot  and  gradually  involve  the  entire  structure ; 
these  abscesses  sometimes  attain  a  considerable  size.  "  It  is 
sometimes  borne  for  a  long  time  without  marked  symptoms,  and 
nature  does  her  utmost  to  prevent  a  free  discharge  of  it  into  the 
peritoneal  cavity ;  for  adhesions  are  formed  between  the  ovary 
and  the  adjoining  viscera,  either  in  consequence  of  peritonitis 


414  DISEASES    OF    WOMEN. 

having  been  combined  with  the  inflammation  of  the  ovary,  or  from 
circumscribed  inflammations  of  the  peritoneum  having  been  set 
up  in  the  course  of  the  ovarian  disease.  When  at  last,  the  sup- 
purative  process  has  eaten  away  the  fibro-serous  investment  of  the 
ovary,  and  caused  its  rupture,  the  discharge  follows,  from  a 
yielding  of  the  adhesions  into  a  circumscribed  cavity;  now  partial 
inflammatory  attacks  of  the  peritoneum  ensue,  or  the  pus  meets 
with  an  organ  which  presents  firm  attachments.  In  the  former 
case,  the  circumscribed  processes  not  unfrequently  pass  into 
universal  peritonitis,  or  this  is  induced  by  an  extravasation  of  the 
pus  through  the  relaxed  adhesions.  Again,  in  either  of  these 
cases,  the  suppuration  may  extend  to  the  adjoining  viscera,  and 
the  contents  of  the  abscesses  be  discharged  outward,  indirectly 
through  a  circumscribed  peritoneal  sac,  or  directly  in  the  hypo- 
gastric  or  umbilical  regions,  or  into  a  portion  of  the  intestine,  into 
the  bladder  or  vagina. 

885.  Summary  of  the  Anomalies  in  other  Organs,  accompa- 
nying the  above-described  jwocesses. — I  have  already  quoted  freely 
from  the  writings  of  Prof.  Rokitansky,  but  under  this  head  I  shall 
give  his  remarks  entire,  as  it  is  probably  the  best  description  uf 
the  disease  extant. 

886.  "  Beside    the  changes  which  occur  in  the  original  seats  of 
the  puerperal  processes  hitherto  examined,  there   are   so    many 
important  and  various  anomalies  in  other  organs  and  tissues,  that 
it  is  not  sufficient  merely  to  give  a  supplementary  account  of  the 
anatomical  results,  but  that  as  copious  an  explanation  of  them  as 
possible    becomes    necessary.      We    shall,   in   the    first   instance, 
describe  and  account  for  the  general  appearance  of  the  body,  and 
then  arrange  the  separate  morbid  processes,  as  much  as  possible, 
in  groups,  according  to  their  mutual  resemblance. 

887.  "  The  dead  subject  presents  a  remarkable  disfiguration  of 
the    countenance,  tumefaction   and   discoloration  of  the  external 
genitals,  excoriation,  ulcerative  destruction  of  various  characters, 
with    or    without    laceration    of    the    perineum,    various    vaginal 
discharges,  tympanitic  distension  of  the  abdomen,  a  livid  erythema 
of  the  common  integument  at  different  parts  of  the  body,  white 
and   often  large   coalescing   miliary   vesicles   on   the    thorax  and 


PUERPERAL     FEVER.  415 

abdomen.     Yellow,   greenish,   bilious,   feculent,  chocolate-colored 
fluids  escape  from  the  mouth. 

888.  "  The    abdomen    presents,   in    most    cases,    even    if    the 
peritoneal    inflammation    has    been    slight    or    entirely   absent,   a 
tympanitic   distension   of   the   intestines;    this   symptom    is  most 
developed  in  universal  peritonitis;  the  entire  intestine  is  then  so 
much   distended   by  gases,  that  it   causes   impressions   upon   the 
uterus,  and  forces  the  epigastric  contents  of  the  abdomen  into  the 
cavity  of  the  diaphragm,  and  with  the  latter  into  the  thorax  as  far 
as   the  fourth  and   third  ribs.     The   firmer  the   exuded   (plastic) 
matter,  the  more  firmly  the  intestinal  coils  and  the  other  abdom- 
inal organs  are  agglutinated  to  one  another  and  to   neighboring 
organs.     The  coagulable  lymph  is  chiefly  contained  in  the  lower 
segment  of  the  abdominal   and  pelvic   cavities,   but  also   in   the 
lateral  parts  of  the  abdomen,  between  the  mesenteries  and  in  the 
vicinity  of  the  large  epigastric  viscera,  within  spaces  that  have 
become    more   or  less    circumscribed    by   the   adhesions.     It   not 
unfrequently  causes,  especially  on  the  surface  of  the  liver,  shallow 
depressions,  and  gives  to  the  superficial  layer  of  this  organ,  if  of  a 
purulent  or   sanious  character,  a  greenish,   and  to   the  spleen  a 
blackish  tinge.     The  reddening  and  vascularity  of  the  peritoneum 
are   generally   inconsiderable ;    but   most   evident    at    those  parts 
which  are  free  from  pressure,  and  take   the  form   of  narrow  or 
broader  strise.     The   membranes  of   the   intestinal   canal  are  all 
tumefied,  the  intersticial  cellular  tissue  infiltrated,  the  layers  easily 
distinguishable  and  lacerable.     The   intestine  generally  contains; 
in  addition  to  a  large  quantity  of  gas,  a  yellow,  serous,  feculent 
fluid,  which  mounts  up  to  the  duodenum  and  stomach.     This  fluid 
is  in  part  the  product  of  an  exudative  process  that  occurs  in  the 
greater  part  of  the  intestinal  mucous  membrane,  and  which  we 
shall  have  occasion  subsequently  to  examine  more  closely.     The 
duodenum  and  stomach  may  also  be  found  to  contain  a  copious 
amount  of  yellowish-green  or  intensely  bitter  green  biliary  fluid. 

889.  "We  have  here  to  advert  briefly  to  two  symptoms  that 
occur  during  the  course  of  puerperal  peritonitis,  and  which  not 
unfrequently  coexist — they  are,  vomiting  of  the  biliary  matters 
contained  in  the  duodenum  and  the  stomach,  and  of  sero -feculent 


DISEASES     OF     TTOMEX. 

matters  from  the  intestine.  The  former  is  to  be  explained  by  the 
paralysis  of  the  muscular  coat  of  the  intestine,  caused  by  the 
peritoneal  exudative  process,  and  the  fixation  of  the  intestine  by 
plastic  exudations ;  it  commences  at  the  duodenum  and  the 
gtomach,  the  peritoneal  covering  of  which  generally  remains  un- 
attacked.  The  latter  is  caused  by  the  exudative  process,  and  the 
consequent  irritation  of  the  intestinal  muscular  coat  which  forms 
a  counterpoise  to,  and  even  counteracts,  the  paralysis  at  some 
points ;  it  is  the  more  frequent  and  the  more  considerable,  the 
less  marked  the  paralyzing  influence  of  the  peritoneal  affection  is. 

890.  "  Almost  all  organs  appear  in  a  state  of  relaxation,  which 
is  proportioned    to   the   primary   or   secondary   dyscrasia  of  the 
blood,  and  to  the  extent  in  which  the  blood  has  become  deprived 
of  its  fibrine  by  the  fibrinous  exudations  caused  by  inflammations 
of  the  peritoneum,  the  pleura,  etc.     It  is  owing  to  a  moistening 
or  imbibition  of  the  tissues  with  the  attenuated  serum  of  the  blood, 
which   easily  exudes   through  the  vascular  coats,  and  is  for  the 
same   reason  coupled  with   pallor  or   discoloration,  owing  to  the 
coloring  matter  which  adheres  to  the  serum.     In  the  abdomen  we 
find  that  the  kidneys  and  the  liver  are  chiefly  distinguished  by  the 
softening,  pallor,  or  pale-red  discoloration,  oedema  and  imbibition, 
relaxation  and  friability  of  their  tissues.     In  the  thoracic  cavity, 
the  lungs  are  chiefly  affected  by  these  and  similar  deviations ;  the 
muscular  portion  of  the  heart,  too,  is,  like  the  other  muscles,  and 
especially  those  that  are  involved  in  the  peritoneal  inflammatory 
process,    soft,  pale,  moist,  and  lacerable.     All  the  serous  mem- 
branes and  the  lining  membrane  of  the  vessel  are  infiltrated  with 
serosity,  and  are  more  or  less  reddened,  and  the  serous  cavities 
contain  various  quantities  of  a  transuded,  pale,  or  dark -red  serum. 
The  brain  alone,  as  in  numerous  other  allied  processes,  e.  g.  in 
typhus,   forms   an  exception,  inasmuch  as  it  appears  denser  and 
harder,  drier  and  paler  than  usual. 

891.  "The    spleen    is    very  frequently,    though    not    always 
tumefied ;  it  is  so  particularly  in  secondary  disease  of  the  blood, 
whether  or  not  accompanied  by  the  secondary  processes  (deposits), 
that  we  shall  subsequently  have  to  notice.     The  lungs  are  reduced 
in  size,  and  denser,  in  consequence  of  the  upward  pressure  exerted 


PUERPERAL     FEVER.  417 

by  the  contents  of  the  abdomen ;  their  inferior  lobes  are  of  a  dark- 
purple  color,  and  in  a  condition  of  hypersemia. 

892.  "We    now   proceed    to    enumerate    the    separate   morbid 
processes  in  the   different  organs,  and  point  out  their  relations  to 
the  original  puerperal  disease. 

893.  "  Our  first  attention  is  due  to  the  exudative  processes  on 
the  various  mucous  and   serous  membranes.     That  affecting  the 
intestinal  mucous   mcm'brane    is   of   particular  importance.     The 
entire  tract  is  generally  involved ;  it  is  but  slightly  reddened,  and 
commonly  exhibits  a  thin,  watery,  serous,  or  viscid-gelatinous,  or 
gelatino-purulent  or  genuine  purulent  product ;  the  tissue  fuses, 
and  the  sub-mucous  cellular  tissue  is  more  or  less  infiltrated.     In 
this  manner  the  diarrheas  of  the  puerperal  state  are  established. 
The  exudation  is  rarely  of  a  firm,  fibrinous,  or  croupy  nature,  but 
most  commonly  its   serous   character   predominates,  and   this   is 
more  the  case  the  larger  or  more  fibrinous  the  product,  resulting 
from  the  coexistent  attack  of  peritonitis.     In  certain  cases,  the 
process  that  takes  place  on  the  mucous  membrane  of  the  colon 
assumes   a  dysenteric  type,  and,  as   in   the   above-named  forms, 
corresponds   to  the  exudation   upon   the   internal  surface  of  the 
uterus  or  to  the   product  of  metrophlebitis.     Similar  processes, 
though   generally   accompanied   with    a    coagulable    product,    are 
occasionally  discovered  on  the  mucous  membrane  of  the  stomach, 
the  oesophagus,  and  the  bladder,  and  in  the  lungs,  in  the  shape  of 
(partial)  apthous   pneumonia ;  this   is  chiefly  the  case  when  the 
blood  has  not  been  exhausted  of  its  fibrine. 

894.  "  Among   the    exudative    processes    that   take    place    on 
serous  membranes,  the  most  frequent,  after  that  occurring  on  the 
peritoneum,  is  pleuritis,  which  is  often  coexistent  with  peritonitis ; 
pericarditis  is  of  less  frequent  occurrence.     We  also  meet  with 
exudations  in  the   synovial  bursse,  and  especially  in  that  of  the 
knee-joint,  the  sterno-clavicular  and  humeral   articulations,  and, 
lastly,  in  the  capsule  of  the  aqueous  humor.     The  exudations  are 
very  copious,  fibrinous,  and  purulent.     A  thin,  soft  exudation  is 
often   found    upon    the    dura   mater,    accompanied    by    a    slight 
reddening  of  the  latter. 

895.  "  All  these  processes   may  be  variously  combined,  and 
27 


DISEASES     OF     WOMEN. 

they  are  dependent  upon  the  primary  or  secondary  disorganization 
of  the  blood,  and  especially  upon  that  caused  by  the  absorption 
of  pus  in  metrophlebitis. 

896.  "Next   in    order   come    the   processes   dependent   upon 
secondary  phlebitis    of  the   larger   veins,    and    of   the    capillary 
venous  systems  of  various  organs  and  tissues. 

897.  "  The  former  are  generally  developed  in  th*e  vicinity  of 
the  original  morbid  affection,  as  in  the  plexus  pampiniformis,  the 
trunk  of  the  internal  spermatic  vein,  the  internal  iliac  and  crural 
veins ;  though  they  frequently,  too,  are  generated  at  a  distance, 
as  in  the  cerebral  sinuses  and  the  pulmonary  artery.     These  give 
rise  to  the   so-called  metastases  or  lobular  abscesses,  which  we 
shall  now  proceed  to  examine. 

898.  "We  often  find  larger  or  smaller  circumscribed  spots  in  the 
most  various  organs  and  tissues ;  the  dark-red  points  of  conges- 
tion,  or   small   accumulations   of  pus   or   sanies,   which   we  have 
repeatedly    adverted    to.       They    are    remarkably    frequent  and 
numerous  in  the  organs  of  sanquification,  especially  in  the  lungs 
and  the  spleen ;  they  are  next  seen  in  the  kidneys,  and  more 
rarely  in  the  ovary ;  they  are  occasionally  met  with  in  the  brain ; 
in  the  thyroid  and  parotid  glands ;  in  all  muscles,  particularly  in 
the  heart ;  in  fibrous  tissues,  as  in  the  dura  mater  and  the  perios- 
teum.    Again,  they  are  very  common  in  the  mucous  tissue,  espe- 
cially of  the  bladder  and  the  intestines ;  they  occur  throughout 
the  cellular  tissue,  but  they  seem  to  predominate  in  the  cellular 
tissue  of  the  extremities,  of  the  mediastina,  of  the  neck,  the  iliac 
muscles,  and  the  intestines  and  stomach." 

899.  "  We  have  already  demonstrated  that  these  processes  are 
genuine  exudative  processes,  or  that  they  consist  in  a  coagulation 
of  the  blood  within  the  capillaries  (capillary  phlebitis).     In  the 
latter  case,  the  coagulum  fuses  in  a  manner  corresponding  to  the 
disease  of  the  blood,  and  to  the  deleterious  matter  absorbed  into 
the  blood,   and   forms   a  purulent  sanious  fluid   or   gangrenous 
pulp." 

900.  "  They  may  probably  be  invariably  considered   as   the 
result  of  a  secondary  infection  of  the  blood,  of  a  poisoning  of  the 
blood  by  the  introduction  of  some  product  from  the  original  nidus 


PUERPERAL     FEVER.  419 

of  disease,  and  particularly  of  venous  pus  and  sanies  in  metro- 
phlebitis.  They  consequently  always  give  rise  to  purulent  and 
sanious  products,  and  terminate  fatally  as  capillary  phlebitis. 
They  enter  into  various  combinations  with  one  another,  and  with 
the  exudative  processes  occurring  upon  serous  and  mucous  mem- 
branes. Owing  to  their  position  at  the  surface  of  the  organs,  we 
always  find  that  pleurisy  supervenes  upon  their  occurrence  in  the 
lungs,  and  peritonitis  upon  their  deposition  in  the  spleen." 

901.  "A  black  softening  of  the  mucous  membrane  of  the  fundus 
ventriculi,   or   of   the   esophagus,  or  of   both    at    the    same  time, 
which  is  indicated  during  life,  by  the  vomiting  of  black  coffee- 
ground   like   matter,    is    of   frequent   occurrence.       It  not  rarely 
reaches  that  degree  of  intensity,  that  the  fundus   of  the  stomach. 
and  sometimes  the  diaphragm  also,  and  the  esophagus,  with  the 
adjoining  cellular  tissue  and  mediastinum  are  ruptured,  and  the 
fluid  that  would  have  been  evacuated  by  the  mouth  is  effused  into 
the  abdominal  and  thoracic  cavities." 

902.  "  After  difficult  labor,  the  cartilages  of  the  pelvic  synch- 
ondroscs  are  liable  to  inflammation,  in  consequence  of  the  traction 
exerted  upon  them,  and  if  the  blood  has  assumed  a  septic  condi- 
tion, the  inflammation  may  terminate  in  gangrenous  fusion  of  the 
cartilage,  the  latter  being  converted  into  a  dirty  brown  and  very 
much  discolored  fluid,  contained  within  the  investing  ligamentous 
tissue." 

903.  "  The  blood  contained  in  the  cavities  and  large  vessels  pre- 
sents various  and  more  or  less  evident  changes.     Its  fibrine  may 
be  converted  into  consistent,  viscid,  greenish-white,  or  yellowish 
coagula;   or  after  previous  extensive  discharges  of  fibrine,  it  may 
be  attenuated,  Avatery,  exuding  through  the  coats  of  the  vessels 
and  the   adjoining  tissues,  and  presenting  but  few  and  trifling, 
gelatinous,    soft    coagula.       Again,    after    previous    purulent    or 
sanious  absorption,  it  is  of  a  dirty  brown-red  or  chocolate  color, 
viscid,  glutinous,  depositing  dirty-white,  opaque,  fibrinous  concre- 
tions, which  in  the  heart  form  numerous  ramifications,  or  present- 
ing dark-red  coagula,  which  are  paler  at  the  surface,  and  fusible. 
Lastly,  if  the  disease  has  run  a  rapid  course,  the  blood  is  much 
reduced  in  quantity,  and  even  without  defibrination  having  taken 


420  DISEASES      OF     WOMEN". 

place,  it  is  attenuated  and  discolored,  and  transudes  all  the  tissues. 
The  fibrine  is  sometimes  found  deposited  on  the  valves  of  the 
heart  in  the  shape  of  vegetations,  without  the  demonstrable  occur- 
rence of  previous  pericarditis.  The  severe  jaundice  aifecting 
women  during  the  puerperal  state,  is  always  dependent  upon 
pyaemia,  and  never  upon  an  appreciable  derangement  of  the  liver." 

904.  Secondary  Terminations. — u  Puerperal  peritonitis  gener- 
ally terminates  in  the  same  manner  as  ordinary  peritonitis ;  we 
notice,  as  particularly  important,  the  unfavorable  terminations  in 
suppurations  —  phthisis  —  of  the  peritoneum    and    the    adjoining 
tissues  (ulcerative  perforations  of  the  diaphragm,  the  abdominal 
parieties,   the   intestines,    the  bladder,   the   vagina,  etc.,)  and  in 
peritoneal  tuberculosis.     The  exudations  upon  the  internal  sexual 
organs  may  become  converted  into  cellular  tissue,  and  by  fixing 
the  tubes  in  an  unfavorable  position,  even  without  occlusion  of  the 
fimbriated  extremity,  cause  sterility." 

905.  "The  exudative  processes  occurring  on  the  internal  sur- 
face of  the  uterus,  as  well  as  the  exudation  in  the  uterine  paren- 
chyma accompanying  the  former  and  metro-phlebitis,  not  unfre- 
quently    degenerate    into    suppuration    of    the    uterus,    and    the 
consequent    purulent    and    sanious    abscesses,    extending    chiefly 
from  the  point  of  insertion  of  the  placenta  in  various  directions, 
may  discharge  themselves  into  the  peritoneal  cavity.     The  affec- 
tion generally  runs  its  course  as  acute  uterine  phthisis." 

906.  "  A  very  remarkable  and  important  result  of  the  exuda- 
tive processes  on  the  internal  surface  of  the  uterus  is  tabes  of  the 
uterus,  which  is  manifested  by  extreme  brittleness  and  friability 
of    the    uterine   fiber.       The    uterus   very   rarely  attains    such  a 
degree  of  involution  as  to  resume  the  size  of  the  unimpregnated 
organ ;  it  generally  remains  considerably  enlarged,  of  the  size  ot 
a  duck's  egg,  or  a  man's  fist ;    its   tissue  at  the  same  time  is 
porous,  of  a  pale  red,  and  at  some  parts  of  a  slate   color ;  the 
insertion  of  the  placenta  continues  visible,  by  the  relaxation  of 
the  tissue  and  the  irregularity  of  the  inner  surface,  or  the  mucous 
membrane  is  at  this  place  invested  by  a  yellowish-white  ashy  sub- 
stance, the  remains  of  the  exudation,  and  generally  presents  a 
retiform  appearance." 


PUEK FERAL     FEVER.  421 

907.  Symptoms. — The  symptoms  of  puerperal  fever  vary  very 
much  in  different  cases  and  in  different  epidemics  of  the  disease ; 
this  variation  in  different  cases,  depends  not  only  upon  the  extent 
of  the  local  inflammation,  on  the  organ  or  organs  attacked,  but 
also  on  the  constitution  and  habits  of  the  patient,  and  the  degree 
of   constitutional  affection.     However  much  the   symptoms    may 
vary  in  different  cases  and   at   different  times,  yet   they  are  so 
marked  as  a  general  rule,  and  indicate  so  distinctly  the  character 
of  the  pathological  lesions,  that  there  is  very  little  danger  of  the 
disease   being  mistaken.      Instead   of  considering  separate]y   the 
symptoms  presented  by  each  of  the  different  local  inflammations 
described  as   metritis.  peritonitis,  etc.,  all  that  is  necessary  for 
practical  purposes,  will  be  to  consider  the  disease  as  it  presents 
the  inflammatory  or    typhoid   form,  or    as  the    inflammatory   or 
typhoid  symptoms  predominate. 

908.  Puerperal  Fever  presenting  more  or  less  inflammatory 
symptoms. — In  a  large  majority  of  cases,  in  the  commencement 
of  the  disease,  whether  it  is  sporadic,  or  occurs  epidemically,  if 
the  local  inflammation  be  the  primary  disease,  it  will  present  the 
inflammatory  form.     In  from  two  or  three  days  to  a  week  after 
delivery,  the   patient  will   complain   of   a  sense   of   lassitude   or 
weariness,  with  sometimes  a  sensation  of  soreness  and  weight  in 
the  hypogastric  region,  and  a  feeling,  as  she  will  express  it,  "  as 
if  she  was  not  getting  along  well."     This  is  shortly  succeeded  by 
rigors  of  greater   or  less  severity,  either  partial  or  general,  to 
which  inflammation  succeeds;  these   rigors   or  chills  may  be  so 
slight,  that  the  patient  would  not  notice  them  without  her  atten- 
tion was  especially  called  to   them,  and  in  this   case,  the  fever 
would  appear  to  have  been  the  first  symptom.     As  soon  as  the 
fever  becomes  developed,  the  face  is  flushed,  the  skin  hot  and  dry, 
there  is  considerable  thirst,  sometimes  nausea  and  vomiting,  and 
a  more  or  less  violent  pain  across  the  forepart  of  the  head.     The 
pulse  during  the  chill  is  full  and  strong,  and  somewhat  accelerated, 
and  as  the  fever  becomes  developed,  it  is  hard  and  quick,  varying 
from  110  to  140  in  a  minute,  and  the  respiration  is  hurried  in  pro- 
.portion.     The  secretions  are  arrested  or  diminished  in  quantity ; 


422  DISEASES    OF    WOMEN. 

the  tongue  is  coated  with  a  white  fur,  and  the  mouth  clammy,  the 
urine  is  high  colored  and  acid,  and  the  bowels  confined. 

909.  With  the  development  of  the  fever  the  local  pain  becomes 
more  or  less  marked,  according  to  the  seat  of  the  inflammation ; 
if  the  peritoneum   is   affected,   it  is   generally   very   severe,  and 
commences  first  in  the  iliac  or  hypogastric  regions,  where  it  may 
continue,  or  it  may  involve  a  large  portion  or  the  entire  abdomen. 
The  tenderness  on  pressure  is  exquisite,  and  as  the  inflammation 
extends,  it  may  become  so  acute  that  the  patient  can  not  bear  the 
slightest  pressure,  not  even  the  weight  of  the  bed-clothes.     In 
those  cases  in  which  the  peritoneum  is  not  involved  in  the  disease, 
the  inflammation  being  confined  to  the  uterus  or  ovaries,  the  ten- 
derness is  not  near  so  great,  the  pressure  having  to  be  made  deep, 
so  that  the  fingers  make  pressure  on  the  inflamed  organs  before 
the  pain  is  much  increased.     The  pulse  likewise  varies  somewhat 
according  to  the  seat  of  the  inflammation,  for  when  the  perito- 
neum is  involved,  it  is  small  and  incompressible — wiry,  while  if 
the  inflammation  affects  the  uterus  and  ovaries  alone,  it  is  gener- 
ally hard  and  full.     It  must  be  recollected,  however,  that  peri- 
tonitis exists  in  six  out  of  every  seven  cases  of  puerperal  fever, 
either  as  a  complication  of  metritis,  or  as  the  primary  disease. 

910.  These  inflammatory  symptoms  may  terminate  in  a  longer 
or   shorter  time,  in  the  typhoid  form.      Sometimes  they  appear 
only  for  the  first  few  hours,  or   they  continue  for  two,  three,  or 
four  days,  or  they  may  continue  to  the  termination  of  the  disease 
either  in  recovery  or  death. 

For  the  first  day  or  two  of  the  disease,  the  lochia  may  continue 
but  grow  gradually  less  and  less  in  quantity,  or  in  some  rare  cases 
it  may  be  suppressed  from  the  commencement,  or  it  may  continue 
throughout  the  course  of  the  disease.  The  secretion  of  milk  is 
in  the  great  majority  of  cases  suspended  in  the  early  part  of  the 
disease,  and  the  mammae  become  flaccid;  though  in  a  few  cases 
reported  this  secretion  has  continued  the  entire  course  of  the 
disease. 

911.  As  the  disease  advances,  all   the   symptoms   mentioned 
become  aggravated,  the  local  pain  and  tenderness  increases,  the 


P  U  E  R  F  E  K  -\  L     F  E  \  E  H .  4  2  o 

patient  lies  upon  her  back,  with  the  thighs  drawn  up  to  'take  off 
the  tension  of  the  abdominal  mu.scles;  the  least  motion  increases 
the  pain,  the  breathing  becomes  shorter  and  laborious,  delirium 
sometimes  sets  in,  there  is  subsultus  tendinum,  and  hiccough,  and 
death  soon  terminates  her  sufferings. 

912.  It  is  very  rarely  that  puerperal  fever  retains  its  inflam- 
matory character  to  the  last,  yet  it  sometimes  occurs,  and  these 
cases  are  marked   by  the    same   symptoms  that   characterize  the 
synochal  grade  of  fever. 

913.  Typhoid  puerperal  fever. — By  the   term  "typhoid"   we 
understand  a  prostrated  condition  of  the  system,  the  vital  power 
being   so   overpowered   by  the   disease   that  a  high  inflammatory 
reaction  is    impossible.     In   this   form  of  the   disease   there  is  a 
greater  or  less  affection  of  the  blood  mass  (septic  condition  of  the 
blood)  caused  cither  by  the  epidemic  influence  in  this  case  being 
the  primary  disease,  or  from  the  absorption  of  some  morbid  mate- 
rial from  the  seat  of  the  local   inflammation    (the    endometritis, 
metrophlebitis,  or  peritonitis).      We   can  readily  understand  why 
puerperal  fever  in  the  majority  of  cases  should  sooner  or   later 
present  these  symptoms  of  great  depression  of  the  vital  power. 
More  or  less  exhaustion  always  succeeds  to  parturition,  from  the 
intense  degree   of  muscular  power  required  to  expel  the  foetus, 
the  circulation  is  likewise  more  or  less  disordered  from  the  rup- 
ture of  the  relations  existing  between  the  mother  and  the  foetus 
in  utero,  and  not   only  this,  but   at   this  time  without  the  excre- 
tions are  free,  there  is  more  or  less  matter  approaching  a  state  of 
disorganization    circulating    in    the    blood,    which   needs   but  the 
stimulation  of  the  epidemic  constitution  of  the  atmosphere  here- 
tofore spoken  of,  to  produce  that   septic  condition   of  the  blood 
which  is  the   essential  condition   of  typhus.     And  not  only  this, 
but  the  uterine   organs   themselves   present  the   very  conditions 
necessary  for  the  absorption  of  morbid  materials  generated  by  the 
inflammatory  process;  there  is  often  ruptures  or  lacerations  of  the 
uterus  or  the  vagina,  through  which  any  putrid  discharges  may  be 
readily  absorbed,  and  the  uterus  presents  at  the  insertion  of  the 
placenta  a  large  traumatic  surface,  with  the  open  mouths  of  the 
utero-placental  veins  constantly  in  contact  with  the  contents  and 


424  DISEASES     OF     WOMEN. 

secretions  of  the  uterine  cavity.  Any  morbid  material  entering 
the  circulation  in  this  manner  is  liable  to  propagate  the  same 
morbid  changes  in  the  blood,  i.  e.,  to  cause  a  disorganization  of 
any  material  in  the  blood  not  sufficiently  vitalized  to  resist  the 
morbid  influence.  It  is  proved  by  experience  that  this  morbid 
process  in  the  blood  is  propagated  in  the  same  manner  that 
diastase  or  yeast  affects  any  albuminous  matter  with  which  it  is 
placed  in  contact.  We  have  a  good  illustration  of  the  effects  of 
the  absorption  of  putrescent  materials,  even  in  very  small  quan- 
tity, in  wounds  made  during  dissection  or  in  making  post- 
mortem examinations,  the  absorbed  material  exciting  such  chemi- 
cal changes  in  the  constitution  of  the  blood,  that  its  whole  char- 
acter is  speedily  changed,  and  its  vital  properties  are  altogether 
destroyed. 

In  a  large  majority  of  cases  as  already  stated,  the  disease 
assumes  the  character  above  described,  the  constitutional  affection 
being  the  principal  disease ;  sometimes  two,  three,  four,  or  more 
days  elapse  before  the  disease  assumes  this  character;  at  others 
it  immediately  succeeds  the  first  inflammatory  reaction,  and  at 
others  it  is  manifest  in  the  commencement  of  the  disease. 

914.  In  the  two  first  instances,  the  first  symptoms  are  those 
heretofore  described,  but  in  a  longer  or  shorter  time  they  are 
succeeded  by  symptoms  of  prostration ;  the  pulse  becomes  small, 
weak,  and  contracted,  though  still  rapid,  the  face  pale,  the  tongue 
more  or  less  coated  with  a  dark  yellow,  or  brown  fur,  or  it  may  be 
clear,  red,  and  dry,  there  is  nausea  and  slight  efforts  at  vomiting, 
diarrhea,  etc.     There  is  a  morbid  heat  or  dryness  of  the  skin,  or 
in  some  rare  cases  there  is  a  constant  clammy  perspiration ;  the 
countenance  presents  a  marked  change,  it  is  sometimes  suffused, 
more    frequently   sallow,    dejected,   ghastly,    and    indicative   of 
extreme  distress ;  the  eyes  are  sunken  and  inexpressive,  and  a 
dusky  livid  ring  may  be  observed  around  the  under  lid. 

915.  The  degree  of  local  pain  varies  very  much,  even  when 
there  is  peritonitis  ;  sometimes  it  is  very  severe,  at  other  times  it 
appears  to  depend  wholly  upon  the  tympanitic  distension  of  the 
abdomen.     The  frequency  and  duration  of  pain  in  puerperal  fever 


PUERPERAL     FEVER.  425 

where  the  peritoneum  was  involved,  was  carefully  observed  by  Dr. 
Ferguson  ;  in  173  of  his  patients  he  found  that 

The  number  of  his  patients  that  had  no  pain  was  19 
"  "          who  had  pain  for  1  day      "    51 

"  «         2  days    «    48 

«  u  u  u  Q       «         a      90 

a  u  «  u  4      u         u     ^g 

a  «  <t  a  5      "         "6 

«  «<  u  n        7     "      "5 

«  u  «  u        8     "       "4 

916L  Shortly  after  the  disease  is  established,  the  abdomen 
becomes  tympanitic,  and  in  some  instances  becomes  very  much 
distended  and  tense,  and  in  a  more  advanced  stage  the  presence 
of  effusion  may  be  detected. 

917.  When  the  disease  assumes  a  low  or  malignant  type  from 
the  commencement,  the  first  indication  of  the  impending  mischief, 
says  Dr.  Copeland,  "  is  the  great  rapidity,  softness,  and  weakness 
of  the  pulse,  often  attended  by  pain  and  tenderness  at  the  epigas- 
trium, by  sickness  and  vomiting,  followed  by  general  distension 
and  pains  darting  through  the  abdomen.  But  in  the  majority  of 
cases  there  are  neither  chills  nor  rigors ;  in  a  few,  a  feeling  of 
coldness  only ;  and  in  still  fewer,  slight  rigors.  In  this  state  of 
=the  disease  the  patient  soon  becomes  despondent,  predicts  her 
-dissolution,  is  afterward  apathetic,  and  makes  little  or  no  inquiry 
for  her  infant.  The  milk  and  lochia  are  either  little  or  not  at  all 
diminished,  or  are  more  than  usually  abundant.  The  abdominal 
pain  and  distension  are  sudden  and  quick  in  their  action ;  but  the 
pain  soon  ceases,  the  distension  remaining,  and  afterward  changing 
its  character,  if  the  disease  continues  above  two  or  three  days. 
The  tongue,  from  the  commencement  is  flabby,  broad,  and  slimy, 
•or  covered  by  a  mucous  or  creamy  coating ;  the  pulse  is  usually 
from  120  to  140,  or  even  upward,  fluent,  soft,  or  broad;  and  the 
general  surface  presents  a  lurid,  dusky,  or  dirty  hue,  and  is 
•covered  by  a  clammy  or  offensive  perspiration.  The  countenance 
is  pale  and  inexpressive,  unless  where  the  pain  is  acute,  when  it 
becomes  anxious  and  covered  with  perspiration.  The  mind  is  but 


426  DISEASES     OF     WOMEN. 

little  disturbed,  beyond  a  state  of  complete  apathy.  As  the 
disease  proceeds,  respiration  is  short,  suspirous,  or  difficult ;  the 
pulse  small,  soft,  or  irregular ;  the  bowels  frequently  relaxed,  and 
the  stools  offensive,  or  passed  without  control.  Distressing  feel- 
ings of  sinking,  leipothymia,  or  restlessness  supervene,  and  are 
soon  followed  by  symptoms  of  impending  dissolution." 

918.  At  any  period  of  the  disease,  the  above-named  symptoms 
may  become  complicated  with  those  arising  from  pleuritis,  gastritis 
or  enteritis,  pneumonia,  etc.     The  occurrence   of   any   of   these 
complications  alter  the  general  symptoms  of  the  disease,  and  they 
therefore  vary  greatly  from  this  cause ;  they  also  vary  much  in 
different  cases  where  no  complications  exist. 

919.  When  the  disease  progresses  toward  a  fatal  termination, 
there  is  effusion  into  the  peritoneal  cavity,  and  with  this  effusion 
there  is  a  remission  of  the  local  pain,  but  with  this  absence  of  the 
local  pain  the   other   symptoms  are   all   aggravated.     The   pulse 
becomes    small    arid   weak,    fluttering,   and   so   rapid  that  it  can 
scarcely  be  counted,  the  patient  appears  to  suffer  more,  and  there 
is  a  constant  watchfulness ;  the  tongue  becomes  dry  and  brown, 
and  there  is  sometimes  vomiting  of  a  dark  coffee-ground  looking 
fluid  :  the  patient  retains  her  position  on  the  back,  and  there  is  a 
constant  tendency  to  slide  down  toward  the  foot  of  the  bed ;  she 
picks  at  the  bed-clothes,   and  appears  to  be  unconscious  of  any 
thing  that  is  going  on  about  her,  etc.     Sometimes  there  is  deli- 
rium, and  when  it  occurs  it  may  be  looked  upon  almost  as  a  fatal 
symptom. 

920.  But  if  the  pulse  be  found  less  frequent  and  stronger,  the 
skin  cool   and  soft,  the  tongue  cleaner,  no  nausea  present,   the 
thirst  less,  and  the  patient  gets  refreshing  sleep,  and  can  change 
her  position  and  lie  upon  her  side,  we  may  hope  for  a  recovery. 

921.  Diagnosis. — From  the  symptoms  above  named,   and  the 
time  at  which  the  disease  occurs,  (shortly  after  parturition)  there 
are  but  two  diseases,  or  morbid  states,  with  which  there  is  any 
danger  of   its   being  confounded ;    these   are,  hysteralgia,  and    a 
disease    described    by   Dr.   Ramsbotham  under    the    name    acute 
tympanitis,  or  false  peritonitis. 

922.  It  may  be  distinguished  from  neuralgia  of  the  uterus  by 


PUERPERAL     EEYER.  427 

the  periodical  exacerbations  and  remissions  of  this  latter,  and 
from  the  less  degree  of  constitutional  suffering.  From  severe 
and  long-continued  after-pains  by  the  fact  that  in  this  the  uterus 
can  be  felt  to  contract  and  harden  with  each  pain,  and  that  there 
is  little  or  no  constitutional  suffering. 

923.  The  diagnosis  between  what  Dr.  Ramsbotham  terms  acute 
tympanitis  and  puerperal  fever  must  be  very  obscure,  from  the 
symptoms  which  he  gives  of  the  disease.  He  says,  "  The  attack 
mostly  commences  two  or  three  days  after  delivery,  and  is  usually 
introduced  by  a  rigor ;  this  is  often  very  severe,  more  so,  indeed, 
than  when  it  proceeds  from  peritoneal  inflammation.  It  is  a  great 
mistake  to  believe  that  shivering  is  always  indicative  of  the  com- 
mencement of  an  inflammatory  attack ;  for  here,  although  not  the 
slightest  appearance  of  inflammation  can  be  observed  after  death, 
the  rigor  is  strongly  marked.  To  this  succeed  great  heat  and 
dryness  of  skin,  which  also  is  often  more  intense  than  in  peri- 
tonitis. I  have  already  said,  that  in  peritonitis  the  surface  is 
sometimes  soft  and  moist  from  the  commencement ;  but  this  I 
never  remarked  in  the  affection  now  under  consideration.  The 
pulse  rises  rapidly  in  frequency,  often  beating  one  hundred  and 
thirty  or  one  hundred  and  forty  strokes  in  a  minute ;  sometimes 
it  is  fluttering  and  tremulous  ;  at  others,  fuller  and  firmer  than  in 
peritonitis.  The  mouth  is  generally  dry ;  the  tongue  occasionally 
furred,  or  it  is  harsh  and  red.  The  countenance  becomes  early 
changed,  though  not  so  anxious  as  in  peritonitis.  Most  severe 
pain  in  the  head  is  experienced,  with  intolerance  of  light  and 
noise,  uninterrupted  wakefulness,  and  in  many  cases  even  delirium. 
Very  early  in  the  disease  the  abdomen  swells  inordinately  and 
rapidly,  becomes  very  tense  and  painful,  and  the  transverse  colon, 
particularly,  can  in  many  instances  be  distinctly  traced ;  pressure 
aggravates  the  sufferings.  The  milk  ceases  to  be  secreted;  the 
lochia  are  generally  suppressed ;  there  is  great  languor ;  an 
unwillingness  to  speak  or  take  nourishment :  the  patient  lies  upon 
her  back,  with  her  legs  drawn  up,  unsolicitous  about  herself,  her 
infant,  or  her  friends ;  the  bowels  are  obstinately  constipated. 
As  the  disease  gains  ground,  the  belly  increases  in  size,  pain,  and 
tightness ;  the  tongue  becomes  dry  and  brown ;  there  is  hiccough. 


428  DISEASES      OF      WOMEX. 

or  vomiting  of  offensive  matter,  muttering  delirium,  subsultus 
tendinum,  and  most  of  the  symptoms  that  denote  the  last  stage 
of  fever ;  but  if  recovery  is  to  be  expected,  the  swelling  and 
tenseness  of  the  abdomen  subside ;  the  pain  gradually  goes  off; 
the  pulse  becomes  slower  ;  the  tongue  moister  ;  the  skin  cooler  and 
softer ;  there  is  no  vomiting ;  the  intellect  remains  unimpaired ; 
and  a  desire  is  expressed  for  food;  and  the  bowels  act,  together 
with  the  expulsion  of  a  large  quantity  of  flatus." 

924.  We  have  here  a  disease  which,  according  to  Dr.  Rams- 
botham,  presents  all  the  characteristics  of  puerperal  fever,  without 
there  being  any  signs  of  local  inflammation   after  death.     This 
would  go  to  prove  the  fact  that  puerperal  fever  is  principally  a 
disease  of  the  blood,  (a  general  or  constitutional  affection,)  and 
not,  as  many  writers  would  have  us  believe,  a  local  affection. 

925.  As  to  the  diagnosis  between  this  and  puerperal  fever,  we 
need  not  trouble  ourselves,  as  they  are  certainly  both  the  same, 
with  the  exception  of  the  local  inflammation,  and  require  similar 
treatment. 

926.  Prognosis. — The  prognosis  in  puerperal  fever  will  vary 
according  to  whether  it  is  sporadic,  or  whether  it  prevails  as  an 
epidemic,  and  according  to  the  character  of  the  epidemics,  some 
that  have  occurred  being  very  malignant,  while  others  have  been 
comparatively  mild.     In  those  cases  that  present  the   symptoms 
of  acute  inflammation  first  named,  the  prognosis   will  be  much 
more  favorable  than  in  those  presenting  a  typhoid  character.    And 
lastly,  it  will  vary  according  to  the  period  of  the  disease  at  which 
the    treatment  is   commenced,  and   the  energy  with   which  it  is 
followed  up.      In  the  language  of  Prof.  Meigs,  "  If  the  nurse 
allow  the  precious  moments  of  the  forming  stage  to  elapse  before 
the  alarm  is  taken,  or  if  the  physician,  through   inattention  or 
failure  in  making  the  diagnosis,  pursues,  in  the  beginning,  a  feeble 
or  erroneous  practice,  no  human  skill,  sagacity,  or  devotion  can 
be  relied  upon  to  rescue  the  victim,  who  has  already  begun  to  die 
before  the  first  hand  is  extended  for  her  rescue." 

927.  Treatment. — The  indications  to  be  fulfilled  in  the  treatment 
of  puerperal  fever  are,  to  subdue  the  local  inflammation  as  soon  as 
possible,  and  thus  prevent  the  severe  constitutional  affection;  to 


PUERPERAL     FEVER. 

stimulate  and  keep  free  the  secretions  and  excretions,  and  thus 
relieve  the  system  of  all  disorganized  material  as  soon  as  formed  ; 
to  neutralize  or  destroy  the  septic  material  as  it  is  introduced  into 
or  formed  in  the  blood  ;  to  rectify  wrongs  of  innervation  ;  and  to 
support  the  strength  of  the  patient  b}'  appropriate  food,  tonics 
and  stimulants. 

928.  A  careful  practitioner  attending  a  puerperal  patient  will 
be  able  to  distinguish  the  disease  at  its  commencement,  or  shortly 
afterward  ;  for,  as  a  general  rule,  it  is  ushered  in  during  his  daily 
attendance.  But  if  an  epidemic  of  the  disease  exists,  careful 
directions  should  be  left  with  the  nurse  or  friends  to  apprise  him 
of  the  first  morbid  symptoms.  As  soon  as  the  disease  is  recog- 
nized, we  examine  the  patient  carefully  to  determine  the  initial 
lesion,  and  promptly  adopt  such  means  as  are  indicated.  I  am 
satisfied  that  this  early  attention  will  many  times  arrest  the  pro- 
gress of  the  disease  in  its  early  stage,  when,  if  neglected  for  a 
single  twenty-four  hours,  the  case  would  be  most  serious.  The 
reader  is  alread}^  aware  that  I  do  not  believe  in  allowing  my  pa- 
tient to  suffer  even  the  usual  aches  and  unpleasantnesses  before, 
during,  or  after  confinement,  and  I  am  always  on  the  alert  for 
these  possible  wrongs.  What  is  described  as  an  ordinary  chill  is 
followed  by  what  the  nurse  calls  milk  fever,  and  the  "busy  prac- 
titioner "  (  a  sj'nonym  for  a  careless  or  lazy  doctor)  takes  it  for 
granted  that  the  nurse  or  attendant  knows,  makes  a  superficial 
examination,  and  comes  back  the  next  morning  to  find  a  fully  de- 
veloped puerperal  fever.  If  it  had  been  taken  in  time,  the  ad- 
ministration of  Aconite  Avith  Macrotys,  or  other  indicated  remedy, 
and  Chlorate  of  Potash  or  Sulphite  of  Soda,  it  might  have  been 
nothing  but  an  ephemeral  fever.  I  wish  to  say  in  this  connection 
that  "  cleanliness  is  next  [better  than]  to  godliness,"  and  the  phy- 
sician who  allows  his  patient  to  lie  in  a  bed  befouled  with  decom- 
posing blood  or  lochial  secretion,  or  allows  the  vagina  to  remain 
clogged  with  decomposing  blood  or  secretions,  falls  far  short  of 
his  duty.  I  have  seen  these  cases,  and-  know  that  they  are  far  too 
common.  I  recall  one  in  which  the  second  day  following  the 
chill  the  patient  had  a  pulse  of  130,  with  a  temperature  of  105°; 
was  furiously  delirious,  with  a  dirty  brown  tongue,  ai'rested  secre- 
Uon  of  urine,  and  exquisite  tenderness  of  the  abdomen — symp- 
toms of  a  most  grave  attack.  The  intensely  putrescent  odor 


430  DISEASES     OP     WOMEN. 

coming  from  the  bed  caused  me  to  make  inquiry  and  an  exami- 
nation, and  I  found  the  clothes  adherent  to  the  vulva  and  thighs, 
the  vagina  packed  with  blood-clots  as  with  a  tampon,  and  the 
uterus  distended  to  some  extent  with  the  lochial  secretion.  The 
removal  was  a  most  unpleasant  job,  and  it  was  some  hours  before 
the  uterus  was  wholly  freed,  but  the  thorough  cleaning  up,  and 
washing  with  chlorate  of  potash,  and  its  internal  administration 
with  tincture  Aconite  and  Macrolys,  were  followed  by  rest  and. 
bleep,  relief  of  the  abdominal  tenderness,  and  a  disappearance  of 
the  puerperal  fever.  In  a  second  case,  wilh  veiy  similar  symp- 
toms, the  removal  of  a  small  portion  of  placenta  which  hud  en- 
gaged in  and  closed  the  os,  was  followed  by  an  abatement  of  all 
the  symptoms. 

929.     I  wish  to  call  attention  to  the  condition  of  the  tongue  in 

O 

the  early  stage  of  the  disease,  as  indicating  remedies.  In  eveiy 
case  we  want  a  good  condition  of  stomach  for  the  reception  and 
absorption  of  medicine,  for  taking  the  necessary  food,  and  for  the 
relief  of  the  sympathetic  nervous  system,  always  unpleasantly 
impressed  by  derangements  of  this  viscus.  We  will  sometimes 
find  our  case,  even  before  the  chill,  with  a  pallid  and  dirty  tongue, 
and  the  conviction  will  come  to  us  that  with  this  dirty  mouth  the 
ordinary  remedies  will  fail  to  exert  their  usual  influence.  Here 
we  give  Sulphite  of  Soda  in  doses  of  ten  grains  every  two  hours, 
until  the  unpleasant  condition  is  removed.  In  another  case  the 
evidence  of  atony,  the  heavily  coated  tongue  at  ba»e,  fullness  and 
oppression  in  the  epigastrium,  and  oppression  of  the  nervous  sys- 
tem, will  suggest  that  it  may  be  well  to  use  an  emetic.  There  is 
a  case  for  Podophyllin,  even  the  old-fashioned  sharp  dose,  and  we 
can  hardly  get  along  without  it,  but  we  must  know  our  case.  The 
face  is  full,  the  tissues  full,  the  tongue  full,  and  especially  the  cu- 
taneous veins  are  full.  Then  we  have  our  cases  of  irritable  stom- 
ach, in  which  the  nausea  and  vomiting  are  unpleasant  features. 
In  one  case  the  sallow  relaxed  fa'ce  and  expressionless  mouth 
with  moist  relaxed  tongue  say,  Nux  Vomica  in  small  dose.  In 
another  the  red  contracted  tongue,  elongated,  and  especially  red 
at  tip  and  edges,  is  the  evidence  of  irritation  and  determination 
of  blood,  and  calls  for  counter-irritation  over  the  epigastrium 
the  small  and  frequently  repeated  dose  of  Aconite  and  Ipecac,  in- 


PUERPERAL     FEVER.  431 

fusion  of  Peach-tree  bark,  or  minute  doses  of  Morphia  with  Bis- 
muth.    These  are  vital  things,  and  should  not  be  neglected. 

930.  In  the  selection  of  the  sedative  we  are   guided  by  our 
general  rules — Veratrum  if  the  pulse  is  full  and  strong,  Aconite 
if  it  is  small.     As  a  rule,  the  Veratrum  may  be  given  with  G-else- 
minum,  Asclepias  or  Dioscorea,  and  the  Aconite  with  Eh  us,  Ma- 
crotys,  Bryoniu,  or  Belladonna.     This   is  only  suggestive  of  the 
associate  remedy,  as  we  are  always  guided  by  the  symptoms.     In 
some  cases  Veratrum   may  be  given   in    large  doses,  (full,  strong 
pulse,  flushed  surface),  say — 1&   Tinct.  Veratrum,  3j.;  Water.  5iv.; 
a  teaspoonful  every  half  hour  or  hour,  until  the  pulse  is  brought 
down  to  its  normal  frequency,  and  then  in  smaller  doses  to  main- 
tain its  influence.     The  Aconite  is  used   in  the   usual  small   dose, 
gtt.  v.  to  gtt.  x.  to  Avater  siv. 

931.  Gelseminum  is  indicated  by  the  flashed  face,  bright  eyes, 
contracted  pupils,  increased    heat   of  the   scalp,  restlessness,  and 
by  scanty  urine  passed  with  great  difficulty. 

Asclepias  exerts  a  most  kindly  influence  in  those  cases  in 
which,  notwithstanding  the  high  range  of  temperature,  the  skin, 
is  moist.  The  Enpatorium  Pert,  is  employed  in  a  somewhat  sim- 
ilar case,  the  pulse  being  full,  oppressed,  and  the  patient  com- 
plaining of  dull  pain  in  the  head.  Both  remedies  are  associated 
with  Veratrum. 

Dioscorea  is  an  admirable  remedy  in  puerperal  peritonitis,  arid 
when  the  intestinal  canal  is  involved.  It  maybe  given  with  either 
the  Veratrum  or  Aconite,  the  tincture  being  added  to  the  prepa- 
ration of  these,  or  it  may  be  given  in  infusion. 

Rhus  is  indicated  by  the  Iturning  pain,  dry  and  constricted  skin, 
sharp  pain  in  frontal  region,  especially  in  left  orbit,  and  sharp 
stroke  of  the  pulse.  It  is  one  of  our  most  certain  and  valuable 
remedies,  and  will  meet  many  unpleasant  cases. 

Macrotys  is  the  remedy  indicated  by  uterine  pains  (as  of  labor), 
and  by  muscular  soreness.  It  is  especially  useful  in  the  forming 
stage  of  the  disease,  and  will  be  replaced  by  other  agents  later. 

Bryonia  is  indicated  by  the  steady  vibratile  pulse,  the  tendency 
to  implication  of  the  serous  membranes  of  the  chest,  as  well  as 
the  peritoneum,  and  by  the  peculiar  pain  in  the  head,  extending 
from  forehead  to  occiput,  especially  on  the  right  side.  The  right 
cheek  is  usually  flushed. 


432  DISEASES     OF     WOMEN. 

Belladonna  is  indicated  by  dullness  of  intellect  and  inclination- 
to  sleep,  and  the  development  of  coma.  It  is  exhibited  in  the 
usual  small  dose  with  Aconite..  I  Avish  to  call  especial  attention 
to  the  use  of  Chionanthus  in  those  cases  which  show  symptoms  of 
jaundice,  with  pain  in  the  region  of  the  liver  and  stomach,  and 
sometimes  nausea  and  vomiting.  Ten-drop  doses  of  the  tincture 
of  Chionanthus  every  two  hours  will  be  found  to  give  much  relief 
and  will  sometimes  arrest  the  progress  of  this  disease. 

932.  Among  the  remedies  which  have  been  deemed  specific  in 
puerperal  fever,  T  ma}'  name  the  Potentillu  Canadensis,  or  cinque- 
foil.     It  may  be  given  in  infusion,  or  the  tincture  used   in  doses 
of  ten  to  twenty  drops  every  two  or  three  hours,  associated  with 
the  sedative. 

933.  Antiseptics.     As    the   fever   progresses    those    symptoms 
known  ns  typhoid  make  their  appearance.     The  reader  will  not 
understand  that  we  have  a  typhoid  fever,  with  disease  of  Peyer's 
glands,  but  only  the  evidences  of  sepsis  of  the  blood  and  prostra- 
tion  that  we  observe   in  typhus  and  typhoid  fevers.     The  word 
"typhoid  "  is  here  used  as  an  adjective  to  denote  a  condition  sim- 
ilar to  that  noticed  in  the  fevers  named.     To  meet  these  symp- 
toms we  use  a  class  of  remedies  called  antiseptics,  and  when  espe- 
cially indicated, .we  obtain  definite  results  from   them.     We  may 
here  consider  the   following  of   this  group — Sulphite  of  Soda, 
Muriatic  Acid,  Sulphurous  Acid,  Baptisia,  and  Chlorate  of  Potash. 

I  may  premise  by  saying  that  the  special  evidences  of  sepsis,  or 
typhoid  disease  of  the  blood,  we  find  in  the  exudation  upon  the 
tongue.  The  tongue  is  moist  and  dirty — nasty — or  the  coatings 
have  a  tinge  of  brown,  growing  deeper  as  the  disease  advances. 
Bad  odors — putrefactive — are  also  evidence  of  typhoid. 

934.  Sulphite  of  Soda.     The  indication  for  this  remedy  is  the 
moist,  pallid,  dirty  tongue.     We  give  it  in  doses  of  from  five  to 
twenty  grains  every  three  hours. 

Muriatic  Acid.  The  indications  for  an  acid  have  already  been 
named — the  deep  red  color  of  mucous  membranes.  The  evidence 
of  the  typhoid  condition  is  brown  coating  of  the  tongue,  sordes 
on  the  teeth,  nervous  prostration,  and  pungent  heat  of  surface. 

Sulphurous  Acid.  This  is  a  very  feeble  acid,  and  is  not  given 
to  fulfill  the  general  indications  for  an  acid.  We  give  it  where 
there  is  normal  color  of  mucous  membranes,  and  where  the  dirty 


PUERPERAL     FEVER.  433 

coat  and  sordes  show  sepsis.     Tt  may  be  given  in  doses  of  ten  to 
thirty  drops  every  three  or  four  hours. 

935.  Baptisia.     It  is  not  so  easy  to  see  the   exact  indications 
for  Baptisia,  yet  it  is  one  of  our  very  best  remedies,  if  the  diag- 
nosis  is  rightly  made.     There  is  a  dull   red   coloration  of  skin 
where  it  has  a  free  circulation,  of  the  lips,  and  of  the  tongue  and 
fauces  ;  or,  as  we  sometimes  say,  there  is  an  o/f-color  of  the  tongue 
— livid,  purplish,  dull  red.     In  the  advanced  stage  of  the  disease, 
the  tongue  is  protruded  with  difficulty,  is  stiff,  fissured,  and  bleeds, 
and  the  tissues  of  the  mouth   and    lances  look   full   and    lifeless. 
The  pulse  is  oppressed,  and   the  skin  is  dry,  husky  and  lifeless. 
The  excretions  are  frequently  fetid.     I  prescribe — R   Tinct.  Bap- 
tisia, gtt.  x.;  water,  siv.;  a  teaspoonful  every  two  hours,  usually 
alternated  with  the  proper  sedative. 

Chlorate  of  Potash.  We  may  get  a  better  idea  of  the  special  in- 
dication for  this  agent  if  we  think  of  it  as  the  remedy  for  the 
puerperal  state.  Given,  offensive  lochial  discharge  following 
abortion  or  delivery  at  full  term,  I  use  Chlorate  of  Potash.  I  use 
this  remedy  in  cynanche  maligna,  and,  as  will  be  recollected,  a 
characteristic  symptom  here  is  the  putrefactive  odor.  So  in  the 
advanced  stages  of  a  fever,  if  there  is  this  unpleasant  odor  of 
decomposition,  i  prescribe  Chlorate  of  Potash,  3!].;  Water,  3iv.;  a 
teaspoonful  every  two  or  three  hours. 

936.  Disinfectants.     We  recognize  the  fact  that  a  patient  suf- 
fering from    puerperal  fever  may  be  poisoned  by  the  exhalations 
from  her  own   body,   by  decomposition  of  the   excretions  in   the 
room,  and  by  dirt  from  any  source.     This  is  something  that  must 
be  thought  of  and   looked  after  in  every  case.     Be  sure  that  the 
bed  coverings  are  kept  clean  ;   that  the  clothing  of  the  patient  is 
changed  frequently  ;  that  the  room  is  kept  clean  ;  that  the  cham- 
ber utensils  are  thoroughly  cleansed  after  use.     See  that  fresh  air 
is  admitted  to  the  room,  and  that  the  foul  air  has  a  chance  to  get 
out  (through  an  open  fire-place,  if  possible,  in  which  a  small  fire 
is  kept.) 

937.  But  if  bad  odors  develop,  destroy  them  with  antiseptics. 
If  in  the  cellar  or  out-buildings,  white-wash  will   answer;  drains 
may  also  be  limed,  or  Chloride  of  Lime  ma}'  be  used.     The  vessels 
about  the  bed  may  be  washed  in  a  solution  of  Chlorinated  Soda, 
or  Sulphurous  Acid,  and  the  air  of  the  room  may  be  disinfected 

28 


434  DISEASES     OF     WOMEN. 

by  a  spray  of  Sulphurous  Acid,  or  a  solution  of  Chlorinated  Soda. 
The  air  spray  apparatus  is  now  BO  cheap  and  good,  that  we  can 
employ  it  more  in  these  cases. 

938.  In  malarial  regions  puerperal  fever  may  be  distinctly  pe- 
riodic, and  require  full  doses  of  quinine,  being  careful  that  the 
patient  is  property  prepared  for  its  use — having  a  soft  open  pulse, 
it  moist  cleaning  tongue,  relief  of  nervous  irritation,  and  a  skin 
inclined  to  moisture.     These  are  the  only  cases  in  which  the  large 
dose  of  quinia  will  prove  beneficial,  and  in  all  others  it  will  most 
surely  do  harm.     In  the  advanced  stage  of  the  disease,  and  when 
we  have  the  fever  under  control,  we  may  use  small  doses  (one 
grain),  as  a  stimulant,  with  good  effect.     Stimulants  ma}*  be  em- 
ployed in  the  same  cases,  giving  small  portions  properly  diluted, 
and  repeated  sufficiently  often  to  keep  up  thegood  effect. 

939.  The  ordinary  use  of  Opium  and  Morphia  by  mouth  is  to 
be  avoided,  a?  it  acts  unkindly  both  upon  stomach  and  brain.     I 
do  not  object  to  the  "  diaphoretic  powder,"  in  five-grain  doses, 
when  it  is  needed  to  give  rest,  if  the  stomach  will  take  it  kindly, 
and  the  pulse  is  soft ;  but  when  the  necessity  for  the  relief  of  pain 
is  imperative,    I    prefer  the   hypodermic  injection  of    Morphia. 
The  medium  quantity  will  be  fifteen  drops  of  a  solution  of  grs.  x. 
to  distilled  water  sj.,  and  the  best  place  for  insertion  will  be  the 
thigh  or  leg,  though  there  will  be  many  reasons  for  taking  the  arm. 

940.  Do  not  use  cathartics  unless  specially  indicated.     It  is 
well  to  open  the  bowels  occasionally,  but  an  enema  is  preferable 
to  medicine  by  stomach,  and  this  can  be  selected  with  reference 
to  the  condition  of  the  bowels,  especially  as  to  the  tympanitis. 
At  first  it  may  be  a  solution  of  compound  powder  of  Jalap  ;  then 
it  may  contain  a  small  portion  of  tincture  Xanthoxylum,  or  even 
turpentine;  and  lastly,  it  may  be  antiseptic,  as  Avith  Chlorate  of 
Potash  or  Chlorinated  Soda. 

941.  To  relieve  the  local  pain,  fomentations  of* Stramonium  or 
of  Hops  may  be  used  in  many  cases  with  great  advantage  ;  they 
should   be  applied  as  hot  as  they  can  be  borne,  and  frequently 
changed,  so  as  to  keep  up  a  continuous  heat;  careful  directions 
should  always  be  given  to  the  nurse  in  regard  to  their  application  ; 
for,  if  left  on  until  they  become  cold,  they  will  aggravate  the 
disease  instead  of  proving  a  benefit;  or  if  they  should  be  applied 
too  wet,  the  patient's  clothes  as  well  as  the  bed  will  become  damp 


P  II  L  E  G  M  ASIA     D  0  L  E  N  S  .  435 

and  make    her  uncomfortable.      From   the   difficulty   of  havin^ 

v  Z3 

fomentations  properly  applied,  several  authors,  among  whom  may 
be  mentioned  Gooch,  Ferguson,  and  Locock,  prefer  a  well-made 
Linseed  poultice,  as  a  constant  application  to  the  abdomen.  The 
best  local  application  with  which  lam  acquainted,  is  the  Tincture 
of  Stramonium,  diluted  with  four  parts  of  water,  kept  hot  on  the 
stove,  and  three  or  tour  thicknesses  of  flannel  wrung  out  of  it  and 
applied  to  the  abdomen  ;  in  changing  it,  the  layer  next  to  the 
abdomen  may  remain,  and  the  applications  made  npon  it;  in  this 
manner  the  abdomen  is  not,  exposed. 

942  Vaginal  injections  of  warm  water  have  been  highly 
recommended  as  afford.  ng  great  relief  in  this  disease;  they  not 
only  assist,  in  relieving  the  local  pain  and  tenderness,  but  they 
also  remove  anv  morbid  secretion  from  the  parts,  and  thereby 
lessen  the  dangers  of  absorption.  If  the  loehia  or  the  discharge 
attendant  on  metritis  be  fetid,  a  weak  solution  of  chlorinated  soda 
be  used. 


PlILEGMASIA    DOLENS. 

944.  This  affection  has  received  and  is  known  under  various 
names,    as,  phlegmasia    dolens,  pldegmasia    alba   dolens,    cedema 
lactium,  sparganosis,  milk  ley,  white  leg,  sivelled  leg,  etc.,  etc.,  and 
as  many  theories  have  been  advanced  in  regard  to  its  character  as 
it  has  names.     It  is  a  disease  of  the  puerperal  state,  occurring 
generally  between  the  fourth  day  and  third  week  after  delivery. 
It  may  arise  after  first  pregnancies,  though  in  a  large  majority  of 
cases  it  occurs  in  females  who  have  borne  several   children  ;  it  is 
also  said  to  arise  more  frequently  in  women  of  a  delicate  consti- 
tution, and  those  who  suffer  from  uterine  irritation  after  delivery. 

945.  The  disease  consists  in  a  colorless  swelling  of  one  or  both 
legs,  the  left  leg  being  said  to  be  more  frequently  affected  than 
the  right  ;   with  swelling,   there  is  pain,  tenderness  on  pressure, 
and  more  or  less  fever.     As  to  the  pathological  lesions  causing 
these  symptoms,  there  are  various  and  conflicting  opinions  ;  some 
regard  it  as  an  inflammation  of  the  veins  of  the  thigh  and  leg,  and 
hence  one  of  its  names,  "crural  phlebitis  ;"  others,  again,  consider 
it  a  species  of  cellulitis,  involving  the  cellular  tissue  of  the  leg, 
while  others  consider  that  the  disease  is  confined  to  the  lymphatics, 


436  DISEASES      OF      WOMEN'. 

and  others  have  combined  these  different  lesions  in  varying  pro- 
portions to  suit  their  individual  fancy.  In  support  of  the  opinion 
that  the  disease  was,  as  one  of  its  names  indicates,  crural  phlebitis,. 
Dr.  Robert  Lee  gives  the  following  conclusions  derived  from  post- 
mortem observations :  "  That  the  inflammation  of  the  iliac  and- 
femoral  veins  gave  rise  to  all  the  symptoms  of  phlegmasia  dolens, 
and  that  the  inflammation  commenced  in  the  uterine  branches  of 
the  hypogastric  veins,  and  thence  extended  to  the  femoral  trunks 
of  the  affected  side."  Prof.  Rokitansky's  observations  go  to 
support,  partially,  this  view  of  the  subject,  yet  he  appears  to 
consider  the  cellulitis  the  prominent  affection ;  he  says  :  "  Two 
lesions  seem  to  be  essentially  connected  with  this  affection.  It 
either  depends  upon  an  inflammation  of  the  veins  of  the  inferior 
extremity,  and  especially  of  the  crural  vein,  or  upon  an  inflamma- 
tion of  the  cellular  tissue,  which  gives  rise  to  the  most  various 
products.  The  latter  form  is  particularly  likely  to  cause  the 
characteristic  symptoms  which  a  so-called  sero-lymphatic  or  sero- 
purulent  product,  i.  e.,  fibrinous  or  purulent  exudation,  diluted  by 
a  large  amount  of  serum,  induces."  Among  those  who  considered 
that  the  lymphatic  system  of  vessels  were  first  affected,  and  that 
the  disease  was  inflammatory,  might  be  mentioned  Drs.  Denman, 
Ferrier,  Caspar,  and  Dewees.  The  reasons  for  this  opinion  are 
well-given  in  a  very  able  paper  by  Dr.  J.  D.  Collins,  of  Kentucky ; 
he  says : 

"  From  a  careful  investigation  of  the  history  and  symptoms  of 
this  disease,  I  have  been  brought  to  the  following  conclusions : 

o  o 

That  it  is  caused  by  the  pressure  of  the  foetus  on  the  numerous 
lymphatics  that  are  located  about  the  lower  part  of  the  superior 
and  upper  part  of  the  inferior  straits  of  the  pelvis. 

"  This  pressure  causes  obstruction  in  the  lymphatic  circulation — • 
this  obstruction  induces  irritation,  and  the  irritation  ultimates  in 
inflammation,  which  soon  involves  the  glands  of  the  whole  of  the 
lower  extremity,  unless  arrested  by  some  agent.  What  are  the 
evidences  upon  which  I  come  to  these  conclusions  ?  They  are  of 
two  kinds,  viz. :  positive  and  negative.  The  positive  are — 

1.  "  That  the  lymphatics  of  the  pelvic  straits  stand  out  more 
prominently  than  any  other  circulating  vessels. 


PIILEGMASIA    DOLEXS.  437 

"2.  "  They  are  less  able  to  resist  pressure  than  any  other 
vessels.  Why  ?  Because  the  visatergo  of  the  lymphatic  circu- 
lation is  more  feeble  than  any  other  circulation  in  these  parts. 

3.  "  There  is  an  effusion  of  lymph  long  before  the  veins  become 
involved.     How  do   I   know  this  ?     1st,  because  of  the  peculiar 
character  and  appearance  of  the  swelling  ;   2d,  because  the  serum 
drawn    off   by    scarifying    the    parts    is    found    to    contain    large 
quantities  of  lymph. 

4.  "Because  we  find  the  lymphatics  much  swollen,  etc.,  before 
the  veins  become  involved. 

"  My  negative  reasons  are — 

1.  "  It  can  not  be  the  veins,  because  the  phenomena  of  inflam- 
mation of  the  veins  is  not  evidenced  in  this  disease,  until  it  has 
existed  for  some  days,  and  sometimes  weeks. 

2.  "  Because    inflammation    of    the   veins    elsewhere    does   not 
present  the  same  appearance  and  phenomena  that  exist  here,  viz.: 
effusion  of  lymph  in  cellular  tissue,  etc. 

3.  "  Because  the  treatment  which  is    successful  in  combating 
inflammation  of  the  veins  elsewhere   does  not  answer  the  same 
purpose  in  this  case. 

4.  "  Because  a  dissection  of  a  portion  of  vein  from  the  diseased 
•parts,  in  its  primary  stage,  does  not  show  any  trace  of  inflam- 
mation. 

5.  "  If    it    were    inflammation    of    the    veins,    resulting    from 
pressure  of  the  fostus  upon  them,  they  would  take  on  the  inflam- 
mation sooner  than  they  do  here. 

"  There  is  no  doubt  in  my  mind  that  the  veins  do  become 
involved  ultimately,  unless  the  disease  is  arrested  in  its  primary 
stage.  All  of  the  post-mortems  show  the  veins,  as  well  as  the 
lymphatics,  to  be  involved,  but  the  post-mortems  are  not  reliable, 
so  far  as  determining  the  primary  cause  of  hardly  any  disease — 
they  only  show  the  extent  of  diseased  action." 

946.  Symptoms. — The  disease  is  usually  ushered  in  with  rigors 
of  greater  or  less  severity,  and  which  continue  for  a  longer  or 
shorter  time ;  these  chills  are  succeeded  by  more  or  less  fever,  the 
pulse  often  rising  to  120  or  140  beats  in  a  minute ;  the  bowels  are 
mostly  constipated,  the  tongue  furred  and  moist,  the  skin  dry. 


438  DISEASES     OF     WOMEX. 

and  the  urine  scanty  and  high  colored.  There  are  also  the  other 
symptoms  of  pyrexia  sometimes  present,  as  headache,  want  of 
sleep,  nausea,  or  vomiting,  etc.  Shortly  after  the  rigors,  the 
patient  complains  of  deep-seated  pain  in  the  hypogastrium  and 
loins,  which  is  soon  referred  to  one  or  other  groin.  In  a  short 
time,  the  affected  limb  commences  swelling,  and  this  is  accom 
panied  with  more  or  less  pain  and  tenderness.  In  a  majority  of 
cases,  the  swelling  will  be  found  to  commence  in  the  calf  of  the 
leg  ;  if  examined,  it  will  feel  hard  and  tense,  and  as  if  it  was 
closely  attached  to  the  bone ;  pressure  at  this  part  will  produce 
considerable  pain.  This  is  a  valuable  diagnostic  symptom,  as  it 
appears  before  the  swelling  of  the  thigh;  it  soon,  however, 
involves  the  entire  upper  portion  of  the  limb.  Dr.  Denman 
observes,  "  that  before  the  appearance  of  any  swelling  or  sense 
of  pain  in  the  limb  about  to  be  affected,  women  become  very 
irritable,  with  a  sense  of  great  weakness,  and  grievously  oppressed 
in  their  spirits,  without  any  apparently  sufficient  reason ;  com- 
plaining only  of  transient  pains  in  the  region  of  the  uterus,  and 
from  these  the  approach  of  the  disease  has  frequently  been 
foretold.  After  a  short  time,  they  are  seized  with  an  extremely 
acute  pain  in  the  calf  of  the  leg,  extending  to  the  inside  of  the 
heel,  and  then,  observing  the  course  of  the  lymphatics,  stretching 
up  to  the  ham,  along  the  internal  part  of  the  thigh,  to  the  groin, 
occasioning  a  slight  soreness  on  the  lower  part  of  the  abdomen." 

947.  The  fever  accompanying  the  disease  generally  assumes  an 
intermittent  or  remittent  form,  the  paroxysms  occurring  in  the 
after  part  of  the  day.     If  the  disease  has  commenced  during  the 
period  of  the  lochial  discharge,  this  will   be  very  apt  to  be  sup- 
pressed, or  become  changed  and  fetid  in  character. 

948.  The  enlarged  limb  is  white,  pale,  and  shining ;  it  may  be, 
and  is  generally,  warmer  than  natural,  though  sometimes  its  tem- 
perature is  not  changed,  and  at  others  it  feels  colder  than  the 
other  limb.     At  the  commencement  and  toward  the  termination 
of  the   swelling,  the  leg  will  be  found  to   pit  upon  pressure,  but 
when  it  is  at  its  hight,  it  is  tense,  and  no  impression  can  be  made 
upon  it.     The  entire  limb  is  more  or  less  tender  on  pressure^ 
though  this  is  particularly  marked  along  the  course  of  the  vessels 


PilLKGMASlA     DOLEXS.  439 

It  is  stated  that  the  femoral  vein  may  be  traced  from  the  groin 
down  the  thigh,  feeling  hard,  or  rolling  under  the  finger  like  a 
cord;  the  inguinal  glands  are  likewise  sometimes  enlarged,  and 
they  have  been  known  to  suppurate. 

949.  Terminations. — Under  appropriate  treatment,  the  disease 
usually  terminates  in  resolution;  the  febrile  symptoms  subsiding 
in  a  short  time,  and  the  swelling    being  gradually  reduced,  the 
patient  regains  the  use   of  her  limbs.     It  is  a  tedious   affection, 
and  it   may  be  months  after  the  acute  symptoms  have  subsided 
before  the  sensations  in  the  affected  parts  will   become  natural. 
Suppuration  may  take  place  in  any  portion  of  the  affected  part, 
involving  more  or  less  of  the  cellular  tissue  of  the  thigh,  leg,  or 
groin ;  the  suppuration  has  been  known  in   some  cases  to  be  so 
extensive  as  to  cause  death  from  the  consequent  exhaustion.      The 
disease  may  terminate  fatally,  though  this  is  not  common.     Dr. 
Burns   says,  "This   is  not  generally   a    fatal    disease;  but   it  is 
tedious    and    often    accompanied  with    hectic  symptoms.     Death, 
however,  may  be    caused    by    suppuration    or    gangrene,   or   by 
exhaustion   proceeding   from   the   violence   of    the    constitutional 
disease  ;  or  by  exertion  made  by  the  patient,  which  has  sometimes 
suddenly  proved  fatal ;  or,  after   the   leg  appears   to  be  getting 
better,  daily  shivering,  with  vomiting,  pain   in   other  parts,   and 
rapid  pulse,  with  delirium  precede  death." 

950.  Diagnosis. — This   disease    may    be    distinguished    by    its 
occurring  shortly  after  parturition,  by  the  tense,  white  swelling 
of  the  limb  affected,  by  the  pain  and  tenderness  along  the  course 
of  the  vessels,  and  by  the  hard,  cord-like,  and  painful  condition 
of  the  femoral  vein. 

951.  Treatment. — "Whilst  we  have  special  remedies  for  this  pecu- 
liar condition  of  the  leg,  we  want  a  e-ood  condition  of  the  stom- 
ach and  intestinal  canal,  and  a  good    condition   of  the   excretory 
organs.     As  a  rule,  we  find  an   unpleasant  condition  of  stomach 
as  indicated  b3rthe  tongue,  aud  this  must  be  rectified  before  other 
remedies  will  act  kindly.     In  some   cases  the  pallid,  sallow,  ex- 
pressionless face,  with  more  or  less  nausea,  and  a  full  expression- 
less tongue,  will  call  for  JSTux  Vomica  in  small  doses.     The  elon- 
gated and  pointed  tongue,  with  reddened  tip  and  edges,  and  ten 
derness  on  pressure  over  the  epigastrium,  asks  for  minute  dosea 


440  DISEASES     OF    WOMEN. 

of  Aconite  and  Ipecac,  with  an  infusion  of  Peach-bark.  The 
pallid  tongue  is  the  indication  for  a  salt  of  Soda,  and  we  usually 
give  it  in  weak  solutions  as  a  drink,  as  much  as  the  patient  wishes. 
The  deep  red  tongue  calls  for  an  acid,  and  we  give  this  as  a  drink, 
either  muriatic  acid,  cider  or  whey.  The  heavily  coated  tongue 
at  base,  bad  taste  in  the  mouth,  and  feelings  of  weight  and  full- 
ness in  the  epigastric  region,  may  require  an  emetic.  The  pallid 
dirty  tongue  asks  for  Sulphite  of  Soda.  And  the  full  tongue,  full 
tissues,  full  veins,  dullness  and  dizziness,  are  the  indications  for 
Podophyllin. 

952.  Other  than  these,  we  commence  the  treatment  with  the 
indicated   sedative,  and  such  special   remedy  as  will   be   named 
hereafter.  There  are  cases  in  which  Veratrum  is  the  best  remecl}' — 
a  vigorous  circulation — pulse  full  and  strong,  and  surface  flushed, 
but  in  the  majority  Aconite  will  be  the  remed}'.     We  use  them  in 
the  ordinary  dose  every  hour  ;  and  in  the  early  stage  of  the  disease 
it  is  well  to~  apply  them   over  the  course  of  the  saphenous  veins. 

953.  Ehus  is  a  prominent  renjedy  where  there  is  burning  pain 
in  the  leg,  frontal  headache,  and  sharp  stroke  of  the  pulse.     In 
one  case  with  the  symptoms  pronounced,  its  action  was  promptly 
curative.     Iris  has  its  indication   here  in  marked  fullness  of  the 
thjToid  glands,  and  in  these  cases  exerts  a  very  marked  influence 
upon  the  affected  limb.     It  should  be  thought  of  in  chronic  cases. 
Phytolacca  is  the  remedy  when  the   tongue  is  pallid,  sore,  Avith 
enlargement  of  lymphatic  glands,  tendency  to  engorgement  and 
inflammation   of  the   breasts,   and   mottled   appearance  of   the 
affected  limb.     A  tincture  of  the  green  root  should  always  be 
employed,  in  the  usual  small  dose  internally,  and  diluted  with  one 
to  three  parts  of  water,  as  an  application  to  the   leg.     Apocy- 
num  is  decidedly  the  remedy  when  there  is  oedema  of  both  feet, 
the  affected    leg  pitting  on   pressure.     The   indications   become 
stronger  if  there  is  fullness  of  the  eyelids,  or   puffiness   of  the 
hands.     If  the  bowels  are  constipated   it  may  be  used  to  the  ex- 
tent of  giving  one  or  two  actions  a  day — say  3j  to  water  siv.,  a 
teaspoon ful   every  three   hours.     Salicylic  Acid   I  am   confident 
will  prove  a  good  remedy  in  those  cases  in  which  there  is  severe 
pain,  with  lochial  fetor,  fetor  of  breath,  the  tongue  having  a  leaden 
pallor.     I  should  give  four  or  five  grains  every  two  hours.     Igna- 
tia  is  indicated  by  morning  chills,  and  coldness  of  the  lower  ex- 


FUNCTIONAL     DISEASES.  441 

tremities,  with  pain  in  the  lower  dorsal  spine.  It  may  be  asso- 
ciated witli  Rhus,  Bryonia,  or  Apocynum.  Belladonna  is  indi- 
cated by  dullness  and  disposition  to  sleep,  and  by  the  abundant 
secretion  of  limpid  urine.  Hamamelis  has  its  usual  indications 
here  in  enfeebled  veins,  swollen  vulva,  and  hemorrhoids,  with 
relaxation  of  the  perineum.  It  is  given  in  doses  of  one-fourth 
teaspoonful  every  three  or  four  hours,  and  the  leg  is  bathed  with 
it.  Apis  will  l)e  indicated  by  stinging  pains,  and  burning  and 
itching  about  the  bladder  and  vulva. 

954.  The  principal  local  remedies  have  already  been  named  as 
we  studied  their  internal  administration.  I  do  not  like  the  use 
of  hot  fomentations  or  poultices,  and  think  the  simple  bathing,  or 
at  least  a  cloth  wet  with  the  agent,  the  best  application.  In  ad- 
dition to  those  named,  I  suggest  Permanganate  of  Potash  (gr.  xx. 
to  water  3iv.)  to  any  part  showing  signs  of  suppuration  ;  and  a 
solution  of  Salicylic  Acid  and  Borax  as  a  wet  dressing. 


CHAPTER     XIV 


FUNCTIONAL  DISEASES. 

955.  FUNCTIONAL  diseases  are  said  to  be  those  "which  are 
dependent  on  deviation  from  the  natural  or  healthy  action  of  any 
part  of  the  organization,  indicated  by  symptoms  during  life, 
•which  on  examination  after  death,  are  found  to  be  unconnected 
with  any  discernible  change  of  structure.  Under  this  head,  we 
class  Leucorrhea,  Amenorrhea,  Dysmenorrhea,  Menorrhagia, 
Chlorosis  and  Hysteria.  We  have  already  noticed  the  numerous 
structural  changes  of  the  uterus  and  its  appendages,  which  are 
capable  of  producing,  and  do  produce,  each  of  these  morbid  con- 
ditions, they  being  but  symptoms  arising  from  the  structural 
diseases,  so  that  the  definition  given  of  a  functional  disease  will 
not  apply  in  a  majority  of  instances  to  these  conditions.  Still,  as 
•each  of  these  diseases  may  arise  without  there  being  any  percept- 


442  DISEASES     OF     WOMEN. 

ible    structural   lesion,  it    is    necessary  to  give  them  a  separate 
consideration. 

LEUCORRHEA. 

956.  Leucorrhea  is  defined  by  Dr.  Ashwell  to  be  :  "  An  exces- 
sive and  altered  secretion  of  the  mucus,  furnished  by  the  mem- 
branes lining  the  vagina  and  uterus,  by  the  follicles  of  the  interior 
of  the  cervix  uteri,  and  by  the  lacunas  of  the  vestibulum ;  gener- 
ally white,  or  nearly  colorless  and  transparent ;  usually  without 
much    odor;    glutinous,   muco-purulent,   or   purulent;    sometimes 
yellow,  green,  or  slightly  sanguinous,  and  of  varying  degrees  of 
consistency.     The  amount  of  constitutional  derangement  depend- 
ing on  the  severity  of  the  affection  and  the  susceptibility  of  the 
patient."     This    definition    correctly  describes  the  symptom,  the 
vaginal  discharge,  but  it  does  not  give  the  slightest  idea  of  the 
cause  producing  the  discharge  called  leucorrhea.     Dr.  Tyler  Smith, 
in  his.  recent  work  on  leucorrhea,  considers  that  hyper-secretion 
of  mucus  is  the  disease,  or,  in  other  words,  that  the  discharge 
is  the  disease,  not  admitting  that  a  previous  change  in  the  struc- 
ture of  the  parts,  or  an  inflammatory  action  was  essential  to  the 
production  of  the  discharge.     He  also  attributes  structural  dis- 
eases, such  as  erosions,  ulcerations,  etc.,  to  this  morbid  discharge. 
He   says :   "  In    maintaining  the  important    part  played   by  the 
cervical  secretions  in  inducing  morbid  conditions  of  the  os  uteri, 
I  do  not  wish  to  be  understood  as  saying  that  they  are  the  only 
causes  of  these  conditions.     What  I  contend  for  is,  that  in  the 
majority  of  cases  in  which  leucorrhea  is  present,  in  combination 
with  non-malignant  disease  of  the  os  and  cervix,  the  morbidly 
active  condition  of  the  cervical  glands  is  the  primary  and  essential 
disorder.     Among  the  other  causes  of  morbid  change  in  the  os 
and  cervix  uteri,  the  varying  vascular  and  mechanical  conditions 
of  these  parts  in  menstruation,  coitus,  pregnancy  and  parturition, 
must   of    course    be    enumerated.      Eruptive    conditions    of   the 
cutaneous  covering  of  the  os  uteri,  in  the  shape  of  aptha,  herpes,. 
or  eczema,  form  another  class  of  causes  of  cervical  discharge,  etc." 

957.  The  first  and  most  important  question  that  arises  in  the 
consideration  of  this  morbid  condition  is,  what  causes  are  capable 
of  giving  rise  to  a  hyper-secretion  of  mucus?   In  considering  this 


LEUCORRHEA.  443 

question,  we  must  bear  in  mind,  that  the  same  causes  that  produce 
a  hvper-secretion  of  mucus  from  other  mucous  membranes,  will 
give  rise  to  it  in  the  mucous  membrane  lining  the  genital  organs, 
and  that  the  same  pathological  laws  govern  diseases  of  the 
mucous  membrane  wherever  situated.  Suppose,  for  instance,  we 
take  the  hyper-secretion  of  mucus  from  the  posterior  nares  and 
upper  portion  of  the  pharynx  as  the  type  of  similar  processes  in 
other  portions  of  the  system,  as  it  is  equally  frequent,  and  can  be 
better  observed.  We  find  that  this  hyper-secretion  depends  upon 
an  inflammatory  action,  which  may  have  been  at  first  acute,  but 
soon  subsides  into  the  chronic  form.  This  chronic  inflammation 
gives  rise  to  permanent  dilatation  of  the  vessels,  to  thickening  of 
the  mucous  membrane,  and  to  hypertrophy  of  the  mucous  follicles  ', 
we  may  observe,  that  the  mucous  membrane  is  tumid,  receiving  an 
inordinate  supply  of  blood,  and  that  this  tumefaction  extends  to 
the  follicles,  which  are  enlarged  and  prominent,  and  with  this 
tumefaction  we  have  an  increased  secretion  of  mucus.  This  pro- 
cess here  and  in  other  portions  of  the  system  is  called  chronic 
inflammation,  and  is  amenable  to  the  treatment  used  for  chronic 
inflammatory  conditions  elsewhere.  Why  the  lining  membrane  of 
the  vagina,  the  cavity  of  the  cervix,  or  of  the  cavity  of  the  uterus 
should  form  an  exception  to  this,  I  am  at  a  loss  to  discover. 

958.  It  has  been  urged  against  this  view  of  the  subject,  that 
the  debility  of  the  system  which  so  frequently  exists,  is  proof 
positive  that  the  local  disease  is  also  one  of  debility.     This,  how- 
ever, is  but  a  poor  argument,  for  it  is  well  known  that  debility  of 
the  entire  system  may  exist,  and  that  there  may  yet  be  a  hyper- 
semic,  congested,  or  inflamed  condition  of  any  single   organ  or 
part. 

959.  That  chronic  inflammation  is   the   cause  of  a  very  large 
majority  of  cases  of  leucorrhea,  I  have  strongest  reason  to  believe. 
I  have  never  been  consulted  in  a  case  of  this  disease  but  what  I 
could  readily  satisfy  myself  of  this  fact.     There  is  no  doubt,  how- 
ever, but  that  there  is  frequently  transient  leucorrhea  without  the 
presence  of  inflammation,  but  these  cases  being  slight  do  not  often 
come  under  the  notice  of  the  practitioner.      Dr.  Bennet  thinks 
"  that   this    term    leucorrhea,  if   retained   at   all,  ought   in  sound 


444  DISEASES     OF     WOMEX. 

pathology,  to  be  reserved  for  those  forms  of  passive  mucous 
hyper-secretion  of  the  vaginal,  cervical,  and  intra-cervical  mucous 
membrane  which  often  temporarily  exist  independently  of  inflam- 
matory lesions,  and  independently  of  uterine  ailment.  These 
passive  and  fleeting  conditions  of  hyper-secretion,  really  and 
truly  are  the  reflex  of  general  conditions  of  health,  and  seldom 
come  under  the  eye  of  the  profession  as  distinct  morbid  states." 

960.  We  have  already  described  the  three  principal  sources  of 
this  discharge,  from  the  vagina,  the  canal  of  the  cervix,  and  the 
cavity  of  the  cervix,  under  the  heads  of  vaginitis,  inflammation  of 
the  cervix  uteri,  and  internal  metritis,  giving  the  character  of  the 
discharge,  the  pathological  conditions  producing  it,  the  means  of 
diagnosis,  and  the  treatment,  and  I  have  only  referred  to  it  in 
this  place  to  direct  the  reader's  attention  to  what  I  consider  to  be 
the  true  pathological  condition  of  the  parts,  when  the  discharge 
("leucorrhea")  exists. 

AMENORRHEA. 

960.  By  amenorrhea  we   understand   the  suppression  of  the 
menstrual  discharge  after  it  has  once  appeared,  or  its  non-appear- 
ance at  the  age  of  puberty,  or  the  age  at  which  it  would  normally 
appear.     The  first  of  these,  in  which  the  menses  having  once 
appeared  are  suppressed,  has  received   the  name  of  "  suppressio 
mensium,"  while  in  the  second,  where  it  has  never  appeared,  it  is 
•called  "emansio  mensium."     We  will  first  consider  emansio  men- 
sium,  or  the  non-appearance  of  the  menses. 

961.  Emansio  mensium,  or  absent  menstruation. — According  to 
Dr.  Carpenter,  "in  the  Human  female,  the  period  of  Puberty,  or 
of  commencing  aptitude  for  procreation,  is  usually  between  the 
thirteenth  and  sixteenth  years ;  it  is  generally  thought  to  be  some- 
what earlier  in  warm  climates  than  in  cold,  and  in  densely  popu- 
lated  manufacturing  towns  than  in   thinly  peopled   agricultural 
districts.     The  mental  and  bodily  habits  have  also  considerable 
influence  upon  the  time  of  its  occurrence;   girls  brought  up  in 
the   midst    of    luxury    or    sensual    indulgence    undergoing    this 
change  earlier  than    those    reared   in  hardihood  and  self-denial. 
The  changes  in  which  puberty  consists  are,  for  the  most  part, 


AMKXOURII  K  A.  445 

connected  with  the  re-productive  system.  The  external  and  in- 
ternal organs  of  generation  undergo  a  considerable  increase  of 
size;  the  mammary  glands  enlarge;  and  a  deposition  of  fat 
takes  place  in  the  mammae  and  on  the  pubes,  as  well  as  over 
the  whole  surface  of  the  body,  giving  to  the  person  that  round- 
ness and  fullness,  which  are  so  attractive  to  the  opposite  sex 
at  the  period  of  commencing  womanhood.  The  first  appearance 
of  the  catamenia  usually  occurs  while  these  changes  are  in  pro- 
gress, and  is  a  decided  indication  of  the  arrival  of  the  period  of 
puberty;  but  it  is  not  unfrequently  delayed  much  longer;  and  its 
absence  is  by  no  means  to  be  regarded  as  a  proof  of  the  want  of 
aptitude  for  procreation,  since  many  women  have  borne  large 
families,  without  having  ever  menstruated." 

962.  Without,  therefore,  the  non-appearance  of  the  menses  has 
produced  a  derangement  of  the  general  health,  we  -can  not  justly 
consider  it  a  pathological  state,  and  any  and  all  medication  should 
be  positively  avoided.     Amenorrhea  here  may  be  dependent  upon 
congenital  deficiency,  malformation,  or  upon  structural  disease  of 
the   genital   organs ;  or  it  may  depend  upon   a  slow  and  partial 
development  of  the  uterine  organs;  or  upon  debility;  or  upon  the 
opposite  condition,  plethora. 

963.  In  the  first  case,  the  ovaries  may  be  wanting,  and  if  this 
is  the  case,  menstruation  as  well  as  conception  can  not  occur;  the 
general  health  may  be   good,  the  body  well   developed,  and  the 
female  strong  and  vigorous.     But  there  will  be  no  development 
of  the  generative  organs,  the  breasts  will  resemble  those  of  the 
male,  the  voice  will  be  deeper,  and  in  all  respects  there  will  be  a 
mixture  of  masculine  with  feminine  peculiarities.    In  this  case,  the 
absence  of  menstruation  will  be  normal.     Again,  the  uterus  may 
be  wanting,  though  the  ovaries  are  present ;  the  female  will  be 
well  developed,  the  breasts  prominent,  and  all  the  characteristics 
of  puberty  present,  with  the  exception  of  the  menstrual  secretion. 
In  this  case,  also,  the  absence  of  menstruation  can  not  be  con- 
sidered a  pathological  condition. 

964.  We  have  already  noticed  in  a  previous  part  of  the  work, 
that  amenorrhea  may  be  caused  by  congenital  or  acquired  occlu- 
sion of  the  os  or  cervix  uteri,  of  the  vagina  or  vulva,  or  from  the 


446  DISEASES     OF     WOMEX. 

presence  of  an  imperforate  hymen.  In  each  of  these  cases,  all 
the  symptoms  of  menstruation  may  be  present,  and  the  menstrual 
fluid  secreted,  but  its  escape  will  be  prevented  by  the  mechanical 
impediment.  The  symptoms,  means  of  diagnosis,  and  treatment 
nave  all  been  given  under  the  separate  heads,  and  the  reader  is 
referred  to  the  previous  description  of  each  of  these  lesions  for 
the  necessary  information. 

965.  The  absence  of  menstruation  may  depend  upon  a  slow  and 
partial  development  of  the  uterine  organs,  either  with  or  without 
general   debility.     In  this  case,  there  is  nothing  to  be  done,  or 
that  can  be  done,  without  this  partial  development  depend  upon 
debility,  when  the  same  measures  recommended  in  chlorosis  should 
be  adopted ;  amenorrhea,  dependent  upon  debility  of  the  system, 
will  also  be  considered  under  the  same  head. 

966.  We  have  then  only  to  consider  amenorrhea  when  it  exists 
in  connection  with  a  full  development   of  the  body  and  of  the 
sexual  organs,  and  when  this  retention  has  caused  more  or  less 
disturbance  of  the  general  health,  the  symptoms  being  those  due 
to  a  vascular  turgescence. 

967.  Symptojns. — According  to  Dr.  Ashwell,  the  symptoms  of 
this  condition  are  "headache,  tension  and  weight  about  the  brain, 
with  a  sensation  of  fullness  and  throbbing  in  the  center  of  the 
cranium,  or  about  the   cerebellum ;   a  florid  countenance,  torpor, 
lassitude ;  pain  in  the  back  and  loins ;  a  full  and  generally  a  slow 
pulse,  though  occasionally,  in  irritable  females,  it  is  rapid ;  irregu- 
lar circulation,  evidenced  by  the  feet  and  hands  being  the  one 
hot  and  the  other  cold,  or  at  short  intervals  both  remarkably  hot 
and  remarkably  cold ;  the  skin  sometimes  harsh  and  dry,  and  at 
others   clammy.     It  is   not  to    be   supposed,   if  the  amenorrhea 
continue,  that  these  symptoms  will  pass  away  after  the  attempt 
at   menstruation    is    over.      They  may  do    so    for   the  first   few 
periods,  but    subsequently  they  continue  during   the    catamenial 
intervals,  recurring  with  aggravation  as  the  menstrual  epoch  again 
approaches.    If  the  malady  has  been  long  neglected,  or  inefficiently 
treated,  a  cure  will  not  soon  be  accomplished.     The  constitution 
sympathizes  so   entirely,   that   months   and    perhaps   years    may 
elapse  before  it  resumes  its  healthy  and  natural  actions. 


AMKXORRHEA.  447 

968.  Causes. — It  is  said  that  this  variety  of  amenorrhea  is  most 
frequently  met  with  in  females  who  have  led  sedentary  and  indolent 
lives,  and  who  have  indulged  in  luxurious  and  gross  diet ;  it  is 
attributed  by  some   authors   to   excessive   uterine   congestion,  to 
torpor  of  the  uterine  vessels,  or  to  spasm  of  their  extremities. 

969.  Treatment. — The  treatment  will  have  to  be  varied  accord- 
ing to  whether  it  be    undertaken  during  an   interval,  or  at  the 
menstrual  period.     If  at  the  menstrual  period,  the  feet  should  be 
bathed  in  warm  water,  and  the  warm  hip-bath  used,  or  instead  of 
this  last  the  patient  may  be  directed  to  sit  over  the  vapor  of  a 
decoction  of  bitter  herbs,   as   tansy,   hops,   etc. ;  this   should  be 
repeated  two  or  three  times  a  day. 

970.  If  there  is  vascular  excitement.  I  would  advise  the  ad- 
ministration of  Aconite  in  the  usual  doses,  with  such  other  rem- 
edy as  may  be  indicated.     Macrotys  has  a  wide  range  of  applica- 
tion here,  the  pain   in  the  pelvis,  back  and  thighs  being  the  indi- 
cation.    With   tensive,   bearing  down   pain.   I   should    substitute 
Viburnum.     If  the  face  is  flushed  and  the  eyes  bright,  with  con- 
tracted pupils,  give  Gelscminum.     If,  in  place  of  vascular  excite- 
ment, there  is  a  feeble   circulation,   sallow  expressionless  mouth 
and   face,  and   pain   simulating  colic,  give   Nux  Vomica,   either 
alternated  with  or  combined  with  Macrotys.     If  the   patient  is 
pale,  despondent  and   nervous,  use  Pulsatilla  and  Macrotys.     In 
cases  where   there  seems  no    special   reason   why  the    discharge 
should  not  appear,  and    none  of  the  above   indications,  the  Gos- 
sypium  may  be  given  in  doses  of  one-fourth  to  one-half  teaspoon- 
ful  every  three  hours. 

971.  In  the  inter-menstrual  period  the  remedies  must  be  care- 
fully selected  with  reference  to  special  indications,  of  which  I  will 
name  a  few.     Iron  is  indicated   by  pallor  and   blueness  of  the 
veins,  with  dull  headache  in  the  back  of  the  head;  Cuprum  by 
the  greenish  sallow  color,  and   small  pulse;  Graphites  by  the  pe- 
culiar clear  and  transparent  skin,  with  tendency  to  hemorrhage 
from  other  parts;  the  hypophosphites  (lime)  b_ypain  in  the  chest 
and  inclination  to  cough  ;  Hamamelis  by  fullness  and  weight  in 
the  perineum. 

972.  In  the  larger  number  of  cases,  having  given  one  of  these 
or  a  restorative  and  bitter  if  needed,  for  the  first  two  or  three 


448  DISEASES     OF     WOMEN. 

weeks,  we  will   give   Macrotys  and  Pulsatilla  in  the  usual  dose,. 
four  times  a  day  for  the  week  before  the  expected  period. 

973.  Suppressio  Mensium,  Suppressed  Menstruation. — Under 
this  head  we  have  to  consider  those  cases  in  which  the  menses 
being  once  established  have  become  suddenly  suppressed.  This 
may  occur  at  any  period  of  menstruation,  or  at  any  age  ;  it  most 
frequently  arises  from  cold  taken  during  the  menstrual  period, 
from  getting  the  feet  wet,  sitting  on  the  damp  ground,  or  cold 
applied  to  the  vulva.  Though  this  is  the  most  frequent  cause,  yet 
it  may  arise  from  severe  mental  emotions  just  preceding  or  during 
the  menstrual  flow ;  from  coitus  during  menstruation,  from  fever 
or  other  acute  disease  commencing  at  this  period,  etc.  I  have  also 
noticed  in  several  cases  that  suppression  of  the  menses  of  a  very 
intractable  character  has  occurred  from  a  long  sea  voyage ;  in  the 
cases  that  I  have  noticed,  menstruation  was  checked  either  at  the 
first  period  after  going  on  board  ship,  or  else  that  after  this  period 
had  passed,  there  were  no  more  symptoms  of  their  appearance 
during  the  voyage,  the  constitutional  suffering  commencing  in  one, 
two,  or  three  months  after  landing. 

9/4.  Symptoms. — The  amount  of  disturbance  consequent  upon 
suppression  of  the  menses  varies  very  much  in  different  cases 
in  some  cases,  there  is  a  slight  headache,  a  feeling  of  weight  in 
the  pelvis,  pain  in  the  back,  and  in  the  limbs,  etc,  but  so  slight  as 
to  give  the  patient  but  little  uneasiness ;  but  more  frequently 
there  is  a  slight  chill,  followed  by  more  or  less  fever,  with  head- 
ache, hot  skin,  quick  pulse,  thirst,  nausea,  etc.  Sometimes  the 
suppression  is  followed  by  inflammation  of  the  uterus,  either 
general,  or  of  the  cervix  only ;  in  these  cases,  the  symptoms 
present  will  be  more  severe.  Dr.  Churchill  states  that  the  most 
puzzling  sequlse  of  suppression  is,  "  a  species  of  hysteria,  simu- 
lating inflammation,  but  without  the  usual  accordance  of  symptoms, 
(some  one  or  other  of  the  important  being  absent,)  and  changing 
from  one  organ  to  another  as  soon  as  our  remedies  are  brought 
to  bear  upon  it.  I  have  seen  the  head,  lungs,  and  stomach 
successively  thus  affected,  and  suddenly  and  apparently  spontane- 
ously relieved.  The  patient  is  very  liable  to  attacks  of  fainting 
and  hysteric  paroxysms."  Capuron  mentions  that  attacks  of  apo- 


AMEXORRHEA.  449 

plexy  and  paralysis  sometimes  result  from  sudden  suppression  of  the 
menses.  Other  authors  state  that  aphonia,  derangements  of  vision, 
amaurosis,  and  cutaneous  disorders  follow  from  the  same  cause. 

975.  These  symptoms  are  very  much  mitigated  in  some  cases 
by  the  occurrence  of  vicarious  menstruation,  or  the  establishment 
of  a  supplementary  hemorrhage  from  some  other  portion  of  the 
body.     The  mucous  membrane  of  the  nose,  of  the  lungs,  stomach, 
and  bowels,  are  the  most  common  seat  of  this  discharge,  though 

O     /  O 

it  has  been  known  to  occur  from  the  axilla,  from  the  ears,  the 
mammas,  the  mouth  and  gums,  fingers  and  toes,  from  ulcers,  in 
fact  from  nearly  every  portion  of  the  body.  This  hemorrhage 
generally  consists  of  blood  only,  and  unless  very  great  in  quantity, 
lasts  for  several  days,  and  it  may  reappear  at  each  menstrual 
period  until  the  menses  are  reestablished.  Though  this  hemorr- 
hage might  at  times  seem  alarming,  as  when  from  the  lungs  to 
indicate  tuberculosis,  yet  when  the  suppression  of  menstruation  is 
taken  into  consideration,  it  has  not  that  importance  which  it 
would  otherwise  have.  This  vicarious  hemorrhage  is  probably  an 
effort  of  nature  to  establish  a  supplementary  issue  for  the  men- 
strual secretion,  which  has  been  suppressed. 

976.  Again,  there  are  other  cases  where  the  suppression  of  the 
menses  does  not  assume  the  acute  form  spoken  of,  the  discharge, 
instead  of  being  at  once  checked,  continuing  for  several  menstrual 
periods,  though  each  time  it  becomes  less  in  quantity  and  lighter 
in  color,  being  preceded  and  succeeded  by  a  leucorrheal  discharge, 
until  at  length  it  does  not   present  the  slightest  trace  of  color. 
This  supplementary  leucorrheal  discharge  occurring  at  each  men- 
strual period  might  be  classed  with  vicarious  menstruation. 

977.  Diagnosis. — There  is  no  difficulty  in  determining  that  the 
discharge  has  ceased,  but  the  important  point  that  we   have   to 
decide  is,  whether  the  cessation  is,  or  is  not,  due  to  pregnancy. 
In  married  women  the  suppression  will  nearly  always  be  attributed 
to  pregnancy,  but  in  some  cases,  both  in  the  married  and  unmar- 
ried, the  female  will  consult  the  physician  for  suppression  of  the 
menses,  hoping  that  the  remedies  used  will  produce  abortion.     In 
such  cases,  therefore,  we  should  be  very  cautious  in  giving  emen- 
agogues,  unless  we  can  satisfy  ourselves  that  pregnancy  does  not 

29 


450  DISEASES     OF     WOMEX. 

exist,  or  if  we  can  not  do  this,  to  use  palliative  measures  until  such 
time  as  it  may  be  ascertained. 

978.  Treatment. — The  first  point  to  be  attended  to  in  this  form 
of  amenorrhea,  is   to   remove   any  inflammatory  condition  of  the 
uterus,  if  this   should  exist,  in  the  manner  heretofore  described. 
If  the  patient  is  seen  soon  after  the  discharge  is  suppressed,  we 
should  employ  such  measures  as  will  tend  to  recall  the  discharge. 
For  this  purpose  her  feet  should  be   bathed  in  warm  Avater,  the 
warm  hip-bath  should  be  used,  or  she  might  sit  over  the  vapor  of 
*  decoction  of  bitter  herbs,  and  some  warm  diaphoretic  infusion 
should  be  given,  as  an   infusion  of  Eupatorium  Perfoliatum  or 
Pennyroyal.     These  maj*  be  called  "  domestic  means,"  and  though 
frequently  successful  in  cases  of  suppression  from  cold,  and  usually 
harmless,  yet  sometimes  they  may  do  serious  injury  by  causing 
an  increased  circulation  to  the  pelvic  viscera,  and  increased  con- 
gestion.    In  place  of  these,  the  modern  treatment  with  small  doses 
of  direct  remedies,  will  give  better  results.     If  there  is  an  excited 
circulation,  give — R  Tinct.  Aconite,  gtt.  viij.;  Tinct.   Macrotys, 
gtt.  xx.;  Water,  siv.;  a  teaspoonful  every  two  hours.     If  the  cir- 
culation is  not  excited,  the  patient  despondent  or  nervous,  use — 
R  Tinct.  Pulsatilla,  Tinct.  Macrotys,  aa.  588.;  Water,  3iv.;  a  tea- 
spoonful  every  three  hours.     If  associated  with  nausea,  abdomi- 
nal pain   (uterine  colic),  give — R  Tinct.  Nux,  gtt.  v.;  Tinct.  Ma- 
crotys, gtt.  xx.;  Water,  s"iv.;  a  teaspoonful  every  hour.     If  there 
is  tensive,  bearing  down  pain,  substitute  Viburnum  for  Macrotys 
in  either  of  these  prescriptions. 

979.  In  some  cases  we  may  see  that  it  is  best  to  give  a  remedy 
that  will  exert  a  more  marked  influence  in  "forcing"  a  discharge 
But  the  case  must  be  carefully  diagnosed.     There  should  be  free- 
dom from  local  disease  of  the  reproductive  organs,  and  an   assu- 
rance that  pregnancy  does  not  exist.     In  such   cases,  half  tea- 
spoonful  doses  of  a  tincture  of  the  Gossypium  (made  from  the 
green  root  before  the  bolls  have  matured)  may  be  given  every 
two  hours  until  the  flow  appears.     If  there  is  excitement  of  the 
circulation,  Aconite  and  Macrotj^s  may  be  given  as  above,  or  if 
there  is  uterine  colic  the  Nux  may  be  used.     There  is  but  one 
case  in  which  I  should  use  Ergot — when  the  patient  was  dull, 
drowsy,  and  showed    evidence  of  want  of   spinal    innervation. 


AMEXO  RRHE  A.  451 

Hero  the  tincture   may  be  used   in   doses  of  ten   or  fifteen   drops 
every  three  hours. 

980.  When   the  patient  has  passed   one    period,  we    use    any 
means  that  may  be  indicated  during  the  first  weeks  of  the  inter- 
menstrual  period,  and   give  SOUK;  remedy  to  favor  the  discharge 
for  the  week  before  it  is  expected.     I  have  been   in  the  habit  of 
prescribing  Pulsatilla   and    Macrotys  for  this  purpose,  and   they 
meet  the  indications   in   a   large  number  of  cases.      But   in   some 
the  Gossy  pi  uni  in  small  doses,  or  other  remedies,  may  be  given. 

981.  In  chronic  suppression,  or  where  the  disease  has  existed 
for  some  time,  and  where  it  is  accompanied   with   a  debilitated 
state  of  the  system,    other  measures  will    have  to  be  employed. 
The  general  health  should  be  restored  by  the  administration  of 
tonics  and  the  preparations  of  iron,  by  the  use  of  the   bath,  and 
appropriate  exercise.     Any  inflammation  of  the  uterus,  especially 
of  its  cervix,  must,  be  removed   by  appropriate  treatment.     The 
frequency  of  inflammatory  disease  of  the  cervix  uteri  in   chronic 
suppression  of  the  menses,  should  always  cause  a  rigid  examina- 
tion of  the   symptoms  present,  and    if  these  should  justify  it.  of 
the  uterine  organs,  both  by  the  touch  and  sight. 

982.  Do  not  imagine  that  Iron  is  the  only  restorative  in  these 
cases.     It  is  a  valuable  remedy  when   indicated,   but  worse  than 
worthless  when  not  indicated.     The  evidences  of  anemia  may  be 
sufficient,  but  blueness  of  veins,  of  lips  and  tongue,  and  dull  pain 
in  the  posterior  part  of  the  head  will  be  better.     In  some  cases  a 
tonic  like  the  triple  phosphate  of  Quinia.  Strychnia  and  Iron,  may 
be  used  with  advantage.     The  compound  syrup  of  the  Hypophos- 
phites  is  a  good   restorative,  as  is  cod-oil,  when  there  is  tendency 
to  scrofulous  inflammation  of  cellular  tissue.     Iodine  or  IShix,  as  in 
the  compound  Iodine  pill,  will  serve  a  good    purpose  in  stimulat- 
ing the  reproductive  function.     Phytolacca  alone,  or  with  Dono- 
van's Solution,  will  be  the  remedy  when  there  is  glandular  disease 
with  cutaneous  eruption,  or  hard,  painful  engorgement  of  cellular 
tissue.     Phytolacca  and  Apocynun>are  used  when  there  is  oedema 
of  the  extremities,  and  the  engorgements  above  named.     Cuprum 
is  indicated  by  the  greenish  pallid  coloration  of  skin  and  tongue; 
Arsenic  by  the  feeble  pulse,  expressionless  tongue,  and  inelastic 
skin,  (minute  doses)  ;  and  Graphites  by  the  blanched  transparent 
skin,  and  inclination  to  menstrual  molimen  yt  frequent  intervals. 


452  DISEASES     OF     WOMEN. 

983.  That  the  reader  may  be  familiar  with  the  emmenagogue 
remedies  in  ordinary  use,  I  may  here  enumerate  as  such  the 
savin,  black  hellebore,  aloes,  gamboge,  etc.,  which  prove  emmena- 
gogue  by  their  drastic  cathartic  effect  upon  the  bowels,  acting 
especially  upon  the  large  intestine,  causing  an  irritation  and 
determination  of  blood  to  the  pelvis,  and  thus  indirectly  proving 
emmenagogue  ;  again,  the  black  cohosh,  blue  cohosh,  and  their 
active  principles,  macrotin,  and  caulophyllin,  guiacum,  madder 
rue,  borax,  etc.,  have  been  termed  emmenagogues,  though  the 
modus  operandi  of  their  action  is  not  known.  Electricity,  mag- 
netism and  galvanism  act  as  direct  stimulants  to  the  uterine 
organs  and  the  nerves  that  supply  them,  and  they  have  therefore 
proved  efficient  emmenagogues.  Of  the  emmenagogue  combina- 
tions that  I  have  seen  used  with  good  effect,  I  may  mention  first 
a  favorite  prescription  of  my  own  in  the  olden  tune  : 

]£  Caulophyllin,  3j. 
Ext.  Aconiti,  gr.    iij. 
Aloes, 
Ferri-Sulphas,  55.  gr.  xxxx. 

M.  Ft.  Pillula,  No.  xxxx.  The  dose  of  these  pills  are  two- 
morning,  noon  and  night.  They  have  thus  far  proved  very 
efficient  in  my  practice,  under  the  circumstances  named.  If  the 
female  be  troubled  with  piles,  however,  the  aloes  should  be 
omitted,  and  one-eighth  of  the  quantity  of  podophyllin  substi- 
tuted for  it.  The  alkaline  tincture  of  guiacum,  formula  of  Dr. 
Dewees,  will  also  be  found  to  be  a  valuable  remedy,  principally  in 
those  cases  where  the  suppression  is  accompanied  with  pain  in 
the  lower  extremities  and  back,  and  a  sensation  of  weight  and 
fullness  in  the  pelvis ;  it  is  composed  of 

"  13*  Pulv.  g.  Guiaci.  opt.  3  iv. 

Garb.  sod.  vel.  Potass.,  5  iss. 
Pulv.  Pimento,  %  j. 
Alcohol  dil.,  Ibj. 

Digest  for  a  few  days."     The  dose   of   this    tincture  is   oi!?~ 


DYSMEXOKiUlEA.  453 

drachm  three  or  four  times  a  day.     Another  combination  which 
Is  used  extensivehT,  is  : 

B  Aloes, 
Myrrh, 

Sulphate  of  Iron,  aa.  5  j- 
Oil  of  Savin,  f.  3  j. 

Make  thirty  pills;  one  of  them  maybe  given  three,  four,  five, 
or  six  times  a  day.  This  list  might  be  increased  almost  indefi- 
nitely, but  these  emmenagogue  formulas  must  be  empirical,  as  the 
disease  occurs  under  so  many  different  circumstances  and  presents 
such  varying  characters.  The  only  rational  mode  of  practice  is, 
to  correct  any  dyscrasia  to  which  the  patient  is  subject,  especially 
any  disease  of  the  uterine  organs,  restore  the  general  health,  and 
nature,  in  a  large  majority  of  cases,  will  re-produce  the  physiolo- 
•gical  menstrual  secretion. 

DYSMENORRIIEA. 

984.  By  dysmenorrhea,  we  understand  a  painful  and  difficult 
flow  of  the  menses,  they  being  generally,  though  not  invariably, 
scanty  in  quantity,  in  severe  cases  containing  clots,  fibrous  shreds, 
or  even  an  entire  false  membrane.    In  many  women,  the  menstrual 
flow  is  always  accompanied  and  preceded  by  pains  in  the  back, 
limbs,  and  in  the  hypogastric  region ;  these  pains,  however,  are 
but  slight  and  of  short  duration,  and  do  not  produce  much  uneasi- 
ness, and  are  not  to  be  considered   as    dysmenorrhea;  but  when 
these  symptoms  are  aggravated,  so  as  to  produce  extreme  suffer- 
ing, this  disease  is  said  to  exist.     We  have  to  notice  three  varie- 
ties   of    this    affection :    Neuralgic  Dysmenorrhea,  Inflammatory 
Dysmenorrhea  and  Mechanical  Dysmenorrhea. 

985.  Neuralgic  Dysmenorrhea. — This  form    of   dysmenorrhea 
may  attack  females  of  any  age,  though  it  is  said  to  occur  more 
frequently   after  the  age   of  thirty  than   earlier    in  life,  and  in 
unmarried  females  than  in  the  married,  or  in  married  women  who 
have  had  no  children.     It   is   also   more  frequently  observed  in 
those  of  a  delicate  and  nervous  habit  of  body,  but  it  may  arise  in. 
those  of  an  opposite  condition. 


454  DISEASES     OF     WOMEX. 

986.  Symptoms. — Sometimes  the  menstrual  period  is  preceded 
for  a  few  days  by  a  disordered  condition  of  the  general  health  ; 
the  bowels  are  constipated,  the  appetite  impaired,  there  is  great 
languor,    irritability,    etc.       Most   generally,    however,    the    first 
symptoms  appear  but  a  few  hours  before,  or  at  the  commencement 
of  the  menstrual  flow.     The  patient  then  complains  of  a  sharp, 
darting,  lancinating  pain  in  the  region  of  the  uterus,  and  which 
radiates  from  this  point  to  the  ovai'ian  regions,  to  the  back,  down 
the  thighs,  etc.;  sometimes  the  pain  in  the  lumbo-sacral  region, 
in  the  groins  and  thighs  is  excessive,  far  worse  than  the  uterine 
pain.     Again,  there  may  be  severe  pain  in  the  mammas,  which 
may  precede  the  appearance  of  the  menses  for  two,  three,  or  four 
days ;  or  it  may  occur  at  the  commencement  of  the  discharge. 
Sometimes  during  the  flow  of  the  discharge,  there  may  be  severe 
expulsatory  pains  resembling  those  of  labor,  and  which  greatly 
aggravate  the  suffering.     There  is  rarely  any  febrile  excitement 
present,   though   the    pulse    is    sometimes    quickened,    and    in   a 
majority  of  cases,  the  skin  will  be  found  harsh   and  dry.     The 
character   and  quantity  of   the   discharge  varies  much  in  differ- 
ent cases ;  sometimes  for  the  first  few  hours,  or  for  a  day  or  two, 
it  is  passed  in  drops,  but  it  then  becomes  free,  and  with  the  free 
discharge    there    is    an    entire    or    partial  cessation   of  pain;  at 
others,    it    may    occur    in    slight   gushes,    each    discharge   being 
accompanied  with  severe  pains,  or  small  clots  or  fibrinous  shreds 
may  be  discharged  at  this  time ;  in  others,  again  it  may  appear  for 
a  day  or  two,  and  then  cease  to  again  reappear,  or  it  may  con- 
tinue  throughout  the  menstrual  period    in    usual  quantity.     As 
soon  as  the  menstrual  period  is  past,  the  pain  ceases,  and  the 
patient  regains  her  usual  health.     This  species  of  dysmenorrhea 
may  exist  for  only  one  menstrual  period,  or  it  may  be  habitual, 
or  it  may  occur  or  be  greatly  aggravated  at  one  period,  and  then 
for  the  next,  or  for  two  or  three  periods,  it  may  be  absent  or  very 
mild,  but  will   again  recur  upon  the   least   over-excitement   or 
exposure. 

987.  Causes. — Cold    is  considered   to   be   the   most   frequent 
cause,   especially   when  taken    during   menstruation,    soon    after 
delivery,  or  after  abortion.     It  is  also  said  to  arise  from  violent 


D  YSMEXO  RR1LEA.  455 

mental    emotions,   sudden   shocks,   etc.,   when    occurring    at  the 
menstrual  period. 

988.  Treatment.— We  have  made  important   additions  to  our 
remedies  for  the  relief  and  cure  of  this  unpleasant  disease  in  the 
past  twenty  years,  aud  a  very  large  proportion  of  eases  may  now 
be  cured  by  the  use  of  internal   remedies   alone,     Even  many  of 
those    which    were   diagnosed   as  ''mechanical    dysmenorrhoea " 
have  been  relieved,  even   after  a  failure   by  dilatation  or  incision 
of  the  cervix.     The  remedies  to  be  specially  studied  in  this  con- 
nection are  the  Pulsatilia,  Macrotys,  Viburnum,  and  Xux,  though 
there  are  others  that  exert  a    very   marked    influence    over  the 
dysmenorrhea   when   specially   indicated.     If  there    is    vascular 
excitement  at  the  commencement  of  the  flow,  I  combine  Aconite 
with  the  Macrotys  or  Viburnum.     Taking  the  ordinary  case,  I 
prescribe — R   Tinct.  Pulsatilla,   Tinct.  Macrotys,  aa.  5ss.;  Water, 
siv.;  a  teaspoonful    four  times  a  day.  commencing   four    to  six 
days  before  the  menstrual  period,  and  continuing  until  it  is  fully 
established  without  pain.     In   chronic  cases  we   repeat  it  every 
month  in  this  way  until  the  desired  object — painless  menstrua- 
tion— is  established,  even  though  it  takes  months  to  accomplish 
it.     The  special   indication  for  Pulsatilla  in  this  case  is  nervous- 
ness, usually  depression.     Viburnum  should   be  chosen  when  the 
pains  are  tensive  and  explosive,  as  if  there  was  something  to  be 
passed.     It  may  be  given  with  Aconite  or  Macrotys,  rarely  with 
either  of  the  others.     Nux  is  the  remedy  for  "  uterine  colic,"  and 
we  have  a  species  of  dysmenorrhea  in  which  the  pain  simulates  a 
colic,  the  patient  being  greatly  prostrated,  with   a  feeble   circu- 
lation, pallid,  sallow  face,  and   sometimes   iiausea.     The  remedy 
may  be  combined  with  Macrotys.  or  Caulophyllum,  or  Dioscorea. 

989.  While  the  remedies  named  are  those  indicated  in  the  ma- 
jority of  cases,  we  will  find   some   in   which   Gelseminum.   Bella- 
donna, Rhus,  Apis,  Ignatia,  Collinsonia.   and   Lobelia,  are  reme- 
dies.    Scanty  and  difficult  urination,  with  flushed  face  and  bright 
eyes,  will  call  for  the  first;  profuse  discharges  of  urine,  dullness 
and  drowsiness,  the  second  ;  burning  pain  and  frontal  headache, 
the  third;  burning,  with  intense  itching,  the  fourth  ;  severe  chill 
and  coldness  of  the  extremities,  the   fifth  ;  tensive,  tearing  pain 
about  the  rectum,  as  if  some  rough   or  pointed    substance    had 
lodged  there,  the  sixth;    great    praecordial    oppression,  difficult 


456  DISEASES     OF     WOMEN. 

respiration,  and  full  rigid  pelvic  tissues,  the  seventh.  This  is  a 
very  brief  description  of  the  remedies  used,  but  every  word  has 
a  meaning,  and  it  will  be  very  difficult  to  mistake  it. 

990.  The   use   of  carbonic   acid  as   a  local  anassthetic  to   the 
vagina  and  uterus,  has  been  strongly  recommended  by  Dr.  Simp- 
son and  others,  in  this  affection,  it  is  said  not  only  to  give  tem- 
porary relief,  but  that  a  permanent  cure  may  be  effected  by  it. 
Dr.  Simpson  uses  a  common  wine-bottle  for  the  formation  of  the 
carbonic    acid  gas,  and   forms    it    by    mixing   in    the    bottle    six 
drachms   of  crystalized    tartaric   acid,   with    a    solution   of   eight 
drachms  of  bi-carbonate  of  soda,  in  six  or  seven  ounces  of  water. 
A  long  flexible  caoutchouc  tube  conducts  the  gas  from  the  bottle 
into  the  vagina.     The  cork  fixing  this  tube  into  the  mouth  of  the 

O  O 

bottle,  should  be  adapted  so  as  to  prevent  the  escape  of  gas  by  its 
sides.  With  this  view,  the  cork  should  be  perforated  by  a 
metallic  tube,  and  covered  externally  with  a  layer  of  caoutchouc. 
Dr.  Dewees  used  the  same  kind  of  an  apparatus,  but  formed  the 
gas  by  mixing  dilute  sulphuric  acid  and  carbonate  of  lime ;  he 
recommended  it  strongly  as  a  palliative  in  carcinoma  uteri. 

991.  In  regard  to  the  benefit  to  be  derived  from  its  use,  Dr. 
Simpson  says :  "  I  have  used  carbonic  acid  as  a  local  anaesthetic, 
principally  in  neuralgia  of  the  vagina  and  uterus,  in  dysmenorrhea, 
and  in  morbid  states  of  the  pelvic  organs,  accompanied  with  pain, 
as  in  carcinoma,  etc.     I  have  found  it  also  sometimes  of  use  in 
irritable  states  of  the  neighboring  organs.     Two  years  ago,  I  had 
under  my  care,  from  Canada,  the   wife   of  a  medical  gentleman, 
who  was  suffering  from  that  most  distressing  disease — dysuria  and 
irritability  of  the  bladder.     Many  modes  of  treatment  had  been 
tried  in  vain.     The  injection  of  carbonic  acid  gas  into  the  vaginal 
canal  several  times  a  day  at  once  produced  relief,  and  ultimately 
effected  a  perfect  cure.     She  has  remained  well  since  her  return 
to  America,  and  lately  became  a  mother.     Occasionally  relief 
follows  immediately.     In  two  or  three  instances  I  have  seen  the 
use  of  the  gas  continued  daily  for  months.     I  have  the  notes  of 
one  case  where  the  patient  was  invalided  and  almost  entirely  kept 
the  supine  posture  for  years,  from  feeling  of  pain  and  bearing 
down  in  the  uterus  and  neighboring  parts,  particularly  on  attempt- 


I)  Y  S  M  E  X  0  K  R  II  K  A  .  457 

ing  to  sit  or  walk.  Many  modes  of  treatment  were  tried  by 
myself  and  others,  with  little  or  no  benefit.  She  has,  however, 
at  last  regained  in  a  great  measure  the  power  of  progression,  and 
freedom  from  suffering  in  the  erect  posture,  a  result  which  she 
herself  ascribes  to  the  local  application  of  carbonic  acid  gas, 
which  I  recommended  to  her  some  months  ago  ;  and  in  the  use  of 
it  she  has  regularly  persevered.  Dr.  Major  states  that  in  dys- 
menorrhea  he  has  employed  the  injection  of  carbonic  acid  gas 
into  the  vagina  in  a  great  number  of  instances,  and  generally 
with  decided  advantage,  the  pain  being  almost  always  relieved  by 
this  treatment.  He  directs  the  remedy  to  be  used  two  or  three 
times  a  day,  and  for  five  or  six  minutes  each  time." 

992.  Inflammatory  Dysmenorrhea. — This  form  of  dysmenorrhea 
presents  nearly  the  same  symptoms  as  the  neuralgic  form  during 
the  menstrual  period ;  but  instead  of  the  patient  being  free  from 
pain  during  the  menstrual  interval,  she  has  all  the  symptoms  of 
the  inflammatory  affection  continuing.     This  form  of  the  disease 
likewise  affects  the  general  health  more  than  the  preceding.     Dr. 
Bennet  thinks  that  we  may  connect    with  inflammatory  dysme- 
norrhea that  form  which  has  been  described  under  the  head   of 
pseudo-membranous,  arid  which  is  characterized  by  the  expulsion 
of  shreds  and  casts  of  plastic  lymph  from  the  cavity  of  the  uterus. 
"  I  believe  that  the  formation  of  these  membranes  coincides  almost 
invariably  with  the  present  or  past  existence  of  uterine  inflamma- 
tion.    In  other  words,  I  have  found,  in  the  great  majority  of  cases 
of  this  description   that  have   come   under  my   observation,  that 
there  has  been  at  first  inflammatory  disease,  although  the  removal 
of  this  disease  has  not  always  freed  the  patient  from  the  liability 
to    the  formation  of   the    pseudo-membranous    casts.      It    would 
appear  as  if  habit  alone  sufficed  in  some  instances  to  perpetuate 
their  formation,  or  at  least  their  occasional  occurrence,  even  after 
the  removal  of  inflammation,  if  they  have  once   occurred  under 
its   influence."      The   production   of  these   dysmenorrheal    mem- 
branes  always  aggravates  the  uterine   suffering,  their  expulsion 
being  accompanied  by  severe  tormina  like  the  pains  of  labor. 

993.  Diagnosis. — This  form  of  dysmenorrhea  may  generally  be 
distinguished  from  the  other  two,  by  development  of  pain  as  a 


45S  DISEASES   OF 

permanent  menstrual  condition  in  a  person  otherwise  menstruat- 
ing without  pain.  In  this  form  likewise  the  symptoms  of  inflam- 
mation will  generally  be  present  through  the  menstrual  interval. 
If  these  symptoms  be  present,  or  if  the  disease  resists  the  usual 
remedies  for  the  affection,  an  examination  should  be  made  to 
determine  the  condition  of  the  uterine  organs,  when  the  inflamma- 
tion will  be  detected. 

994.  Treatment. — The  treatment  during  the  menstrual  flow  will 
be  the  same  as  for  neuralgic  dysmenorrhca.  our  object  being  to 
mitigate  the  pain   and   promote   the   menstrual   discharge.      But 
during   the  menstrual  interval  our  efforts  should  be  directed  to 
the  removal  of  the  inflammation  ;  this  being  the  cause  of  the  pain- 
ful menstruation,  its  removal  will  be  followed  by  a  cure  of  the 
dysmenorrhea,  which  is  but  a  symptom. 

995.  Mechanical  Dysmenorrhea. — The  term  mechanical  dysme- 
norrhea is  applied  to  that  form  which  is  supposed  to  arise  from 
striciure  of  the  canal  of  the  cervix.     The  attention  of  the  profes- 
sion was  first  called  to  this  cause  by  Dr.  Mackintosh  of  Edinburgh. 
He  states  that  he  has  found  it  a  very  frequent  cause  of  the  affec- 
tion, though  this  is  denied  by  other  authors.     There  can  be  no 
doubt  that  stricture  of  the  cervix,  either  congenital  or  acquired^ 
does    sometimes   exist,   but  from  the  contradictory  statement  of 
authors  it  is  impossible  to  determine  its  frequency ;  when  it  does 
exist,  however,  it  may  be  a  cause  of  dysmenorrhea.     The  symp- 
toms of  this  form  of  dysmenorrhea  do  not  differ  materially  from 
those  of  the  other  forms.     The  peculiar  character  of  the  dysme- 
norrhea, when  caused  by  congenital  contraction,  according  to  Dr. 
Bennet,  is  the  absence  of  any  uterine  symptom  during  the  interval 
of   menstruation,    and    intense   agonizing   pain   for  a  few  hours 
before  the  flow  of  blood  appears,  either  then  disappearing,  or 
lasting  throughout  the  period ;  these  pains  commencing  with  men- 
struation in  early  youth.     The  obstruction  may  merely  be  at  the 
os  internum,  spasmodically  contracted ;  in  which  case,  as  soon  as 
it  has  been  overcome,  the  blood  escapes  freely,  and  pain  disap- 
pears.    But,  if  the  os  internum  is  permanently  contracted,  or  the 
contraction  exists  in  the  cervical  canal,  the  pain  may  continue 
throughout  the  catamenial  period. 


MEXORH  IF  AC,  IA. 

996.  Treatment. — Where  it  is  ascertained  that  the  dysmcnorr- 
hea  is  dependent  upon  contraction  of  the  cervical  canal,  it  may 
be  relieved  by  its   cautious   dilatation.     This   dilatation   ma,y  be 
effected  by  the  use  of  graduated  elastic  or  metallic  bougies,  com- 
mencing with  one  of  a  small  size,  and  gradually  increasing  it  until 
the    canal    is    sufficiently    dilated.      In    using    these    bougies    the 
patient   should  be  placed  in   the   usual    position   for  making    an 
examination,  the  index-finger  of  one  hand  being  introduced  to  the 
cervix  uteri,  the  bougie  may  be  guided  by  it  to  the  os,  and  by  a 
slight  rotatory  motion  it  should  be  carefully  introduced  through 
the  cervix  to  the  fundus.     The  frequency  with  which  the  bougie 
is  introduced,  must  depend  altogether  upon  the  degree  of  irrita- 
tion it  produces;  if  any  should  arise,  every  two  or  three  days  will 
be  sufficient.     Incision  of  the  cervix  uteri  has  been  recommended 
and  many  instruments  have  been  devised  for  the  purpose.  The  one 
in  most  common  use  is  made  like  a  pair  of  scissors,  the  cutting 
blades  shutting  into  a  staff  like  a  uterine  sound.     The  instrument 
being  introduced  as  far  as  the  operator  deems  it  necessary,  the 
blades  are  spread  and  allowed  to  cut  their  way  out  as  the  instru- 
ment is  withdrawn.     I  think  its  use  objectionable. 

997.  Each  of  the  three  varieties   of  dysmenorrhea  generally 
causes  sterility ;  this  is  almost  invariably  the  case  in  the  severe 
forms,  but  in  the  slighter  impregnation  may  occur.     If  conception 
does  occur,  it  may  be  followed  by  an  entire  disappearance  of  the 
dysmenorrhea  afterward. 

MENORRIIAGIA. 

998.  Menorrhagia,  or  profuse  menstruation,  may  occur  at  any 
age,  and   either  in   the  plethoric   and  robust,  or  in   those   of  a 
delicate   and   exhausted  habit  of  body.     The  term   menorrhagia 
signifies  merely  an  increase  in  the  catamenia,  the  standard  with 
which  it  is  compared  being  the  normal  quantity  discharged  by  the 
female,  and  not  any  definite  amount  supposed  to  be  the  average 
quantity  of  blood  discharged  during  menstruation.     Thus,  in  some 
females    the    discharge    is    always    very    profuse,    and   yet    still 
compatible  with  health,  while  this  same  amount  of  discharge  would 
be  considered  as  menorrhagia  in  others.     Excessive  menstruation 
may  occur  in  two  ways ;  either  as  it  regards  the  frequency  of  its 


460  DISEASES     OF      WOMEN. 

return,  or  the  quantity  lost  at  each  period  :  in  the  first,  the 
excessive  menstrual  discharge,  either  as  to  frequency  or  quantity, 
is  the  normal  uterine  secretion,  showing  no  tendency  to  coagulate 
either  within  the  uterus  or  when  discharged ;  in  the  second,  the 
discharge  is  actually  a  hemorrhage,  resulting,  probably,  from  an 
exhalation  from  the  uterine  vessels,  the  'discharge  coagulating  both 
•within  the  uterus,  forming  clots,  and  after  it  has  passed  from  the 
genital  organs.  These  two  varieties  we  will  consider  separately. 

999.  Menorrhagia,  with  the  discharge  of  the  normal  menstrual 
fluid. — As  I  have  already  stated,  we  have  no  standard  by  which 
we  can  determine  the  existence  of  this  species  of  menorrhagia; 
the  fluid  being  normal  in  quality,  its  variation  in  the  frequency  of 
its   recurrence,  or  in   the   quantity   discharged,  will    have  to  be 
determined  by  the  previous  history  of  the  patient.     Thus,  if  the 
periods  of  recurrence  were  twenty-eight  days,  the  appearance  of 
the  menses  at  intervals  of  two  or  three  weeks  would  be  called 
menorrhagia;    or,  if  the  normal  quantity  discharged  was  six  or 
•eight  ounces,  the  loss  of  fifteen  or  twenty  ounces  would  be  profuse 
menstruation,  and  still  each  of  these  circumstances,  occurring  in 
other  females,  would  be  normal. 

1000.  Symptoms. — The  symptoms  attending  profuse  menstrua- 
tion   are    such    as    we    should    anticipate    from    any    exhausting 
discharge ;  thus,  there  is  debility,  languor,  inactivity,  the  face  is 
pale,  the  hands  and  feet  cold,  etc.     There  is  generally  a  sensation 
•of  weakness   or  slight   pain   in   the   back,  and,   as   the   disease 
continues,  a  constant  aching,  more  or  less  severe,  in  the  lumbar 
regions,  in  the  hips  and  thighs,  and  in  the  hypogastriurn.     "If," 
says  Dr.  Churchill,  "the  disease  be  not  relieved,  and  especially  if 
uterine  leucorrhea  be  present,  all  these  symptoms  become  aggra- 
vated.    The  exhaustion  and  languor  increases,  the  face  becomes 
sallow,  an  aching  pain  is  felt  across  the  loins,  extending  around 
the  lower  part  of  the  abdomen  ;  pain  in  the  left  side,  repeated  and 
severe  headaches,  derangement  of  the  stomach  and  bowels ;  in 
short,  all  the  secondary  symptoms,  and  the  derangement  of  the 
health  which  follow  in  the  train  of  anemia,  no  matter  in  what  way 
this  may  have  been  produced.     In  some  extreme,  but  rare  cases, 


MEXORHIIAGIA.  461 

we  have   diarrhea  and  anasarca,  with  nervous  symptoms,  melan- 
choly, and  even  epilepsy  resulting  from  this  disorder." 

1001.  Causes. — As  already  stated,  menorrhagia  of  this,  as  Avell 
as  the  other  variety,  may  occur  both  in  the  debilitated  and   the 
plethoric,   though  much   more   rarely  in   the   latter.     It  may  be 
caused    by    cold,    by    too    great    physical    exertion,    or    mental 
excitement,  and,  it  is  said,  from  immoderate  sexual   indulgence. 
A  very  frequent  cause  of  menorrhagia  is  undue  lactation ;  it  also 
arises  from  hemorrhage  after  parturition  or  abortion. 

1002.  Treatment. — The  treatment  of  profuse  menstruation  will 
vary  according  to  whether  the  patient  is  plethoric  or  debilitated, 
but  in  either  case  the  first  indication  is  to  remove  the  exciting 
cause. 

1003.  In  the  plethoric,  if  the  discharge  is  not  too  profuse,  and 
it   can  not  well   be  if  the   discharge   still   retains   the   menstrual 
character  and  the  patient  is  not  debilitated,  but  little  treatment  is 
necessary    during    the    menstrual    period.      If    the    discharge    is 
excessive,   the   patient   should  keep   the   recumbent  posture,  the 
room  kept  cool,  and   the  diet  plain   and   unstimulating,  and   all 
kinds  of  excitement  avoided.     If  the  bowels  are  constipated,  they 
may  be  evacuated  by  the  administration  of  the   Carbonate,  Sul- 
phate, or  Citrate   of  Magnesia,  or  by  the  use  of  laxative  enemas. 
If  Ave  should  Avish  to  check  the  discharge,  cold  Avatcr  or  vinegar 
may  be  applied  to  the  abdomen  and  vulva1  Avith  the  internal  ad- 
ministration of  the  tinctures  or  the  oils  of  Erigeron  and  Cinna- 
mon, or  small  doses  of  ipecac. 

1004.  During  the  menstrual  interval  the  diet  should  be  plain 
and  unstimulating;  daily  exercise  in  the  open  air  should  be  taken  ; 
the  bowels  kept  regular,  and  the  cutaneous  secretions  free  by  the 
daily  use  of  the  bath, 

1005.  In  the  debilitated  it  is  important  that   this   exhausting 
discharge  should  be  checked  as  soon  as  possible.     In  passive  ute- 
rine hemorrhage  I  have  placed    more   dependence  upon    Carbo- 
veg.,  2d  decimal   trituration,  than   any  other  remedy,  though   of 
course  it  is  not  adapted  to  all   cases.     I  give  it  in   grain   doses; 
every  one  to  four  hours,  and  usually  follow  it  with  the  tincture  of 
Cuprum  as  a  blood  maker.     When  the  eyelids  look  full,  or  slight 


462  DISEASES     OF     WOMEX. 

swelling  of  the  feet.  Apocynum  is  the  remedy,  gtt.  x.  being  added 
to  half  a  glass  of  water,  and  given  in  doses  of  a  teaspoonful  every 
hour.  Ergot  may  be  employed  in  some  cases,  but,  I  would  restrict 
it  to  those  in  which  the  uterine  globe  had  been  enlarged  from 
some  cause,  or  in  which  there  was  marked  evidence  of  want  ot 
spinal  innervation.  Gallic  Acid  is  one  of  the  older  remedies,  and 
may  be  used  in  doses  of  three  to  five  grains  every  two  hours. 
The  oil  of  Erigeron,  in  doses  of  five  drops,  or  tincture  of  Cinna- 
mon in  3ss.  doses  as  often  as  necessary,  is  also  recommended. 
The  Erigeron  or  Cinnamon  maybe  combined  in  the  form  of  tinc- 
ture, if  the  physician  prefers  it.  If  nothing  better  is  at  hand, 
small  portions  of  grated  nutmeg  with  alum  will  serve  the  purpose. 

1006.  During  the  menstrual  interval,  such  measures  will  have 
to  be  employed  as  will  restore  the  general   health ;  and  by  this 
means    prevent   the   excessive   discharge   at   the   next    menstrual 
period.     In  addition  to  the  means  employed  for  this  purpose,  the 
patient  should  make  daily  use  of  vaginal  injections  of  cold  water, 
and,  in  addition  to  the  daily  sponge-bath,  the  entire  pelvis,  loins, 
and    hypogastrium    may   be   bathed    daily   witK^Salt  water,    and 
accompanied  with  brisk  frictions  with  the  "hand ;'  this  will  be  found 
to  be  an  important  means  of  restoring  tone  and  vigor  to  the  pelvic 
organs.     For  the  week  preceding  the  next  menstrual  period  the 
patient  may  use  with   advantage  the  trituration  of  Carbo-veg.  in 
grain  doses  four  times  a  day. 

1007.  Menorrhagia,  with  the  discharge  of  blood  directly  from 
the  uterine  vessels,  the  discharge  being  coagulable. — This  variety 
of  menorrhagia  is  of  very  rare  occurrence,  without  there  exists 
some  structural  disease  of  the  uterus,  which  may  be  detected  by 
an  examination.     This  form  of  menorrhagia  may  occur  either  in 
the  robust  or  plethoric,  the  hemorrhage  being  acute,  or  in  those  of 
a  debilitated  or  feeble  constitution,  the  hemorrhage  being  passive. 

1008.  Symptoms. — In  active   menorrhagia,  says    Dr.  Ashwell, 
"  there  generally  exists  immediately  before  the  expected  period, 
and  occasionally  for  a  few  days    prior  to  the  flow,  considerable 
tension  and  fullness  within  the  pelvis,  accompanied  by  a  feeling 
of  weight  and  throbbing  in  the  uterus.     The  mammae  often  sym- 
pathize, becoming  tumid,  hot,  and  tender  on   pressure,  and  the 
external  genitals  are  sometimes  slightly  s woolen  and  painful.    The 


MENORRHAG1A.  463 

pulse  is  quickened,  there  is  oppression  of  the  head,  and  often 
decided  headache,  with  sympathetic  fever.  In  this  way  the  acute 
or  active  form  of  menorrhagia  is  ushered  in,  and  is  throughout 
characterized  by  a  predominance  of  inflammatory  or  spasmodic 
symptoms,  or  by  a  combination  of  both.  When  inflammation  is 
present,  there  will  be  fixed  pain  in  the  uterine  regions ;  a  hot,  dry 
skin,  and  a  frequent,  hard  and  full  pulse.  Where  spasm  prevails, 
the  pain  will  not  be  constant ;  but,  having  continued  a  longer  or 
shorter  time,  and  often  most  severely,  it  will  subside,  and  after  an 
interval  again  occur  with  throes  resembling  the  pains  of  labor. 
The  discharge,  too,  is  equally  variable,  ceasing  for  short  periods, 
during  the  pain,  and  returning  when  it  subsides.  The  pulse, 
during  the  spasm,  is  contracted,  irritable,  and  quick ;  afterward  it 
becomes  softer  and  slower,  giving  proof  by  this  rapid  change  of  a 
state  of  the  system,  neither  of  inflammation  nor  debility,  but  of 
irritation.  The  progress,  duration,  and  severity  of  these  attacks 
are  extremely  variable.  Sometimes  the  discharge  comes  on  and 
continues  by  gushes,  and  numerous  coagula  are  expelled.  The 
patient,  in  many  instances,  is  thus  relieved,  the  headache,  tension, 
and  pain  in  the  uterine  region  are  quickly  diminished  ;  the  pulse 
is  softer  and  less  quick ;  the  skin  cooler  and  moist ;  and  the 
remainder  of  the  period  is  passed  over  with  tolerable  comfort.  In 
the  more  protracted  and  aggravated  cases,  the  discharge  often 
continues  from  three  to  six  days,  not  without  diminution,  but  still 
with  such  proneness  to  return,  that  the  patient  is  compelled  to 
avoid  exertion,  and  to  maintain  almost  constantly  the  recumbent 
position.  On  the  subsidence  of  the  flow,  she  is  weak  and  exhausted, 
and  several  days  elapse  before  she  regains  her  usual  freshness  of 
countenance  and  strength  of  pulse.  It  is  easy  to  mark  the 
transition  from  this  to  the  passive  form  of  menorrhagia ;  for, 
although  at  first,  the  recurrence  of  the  events  just  now  described, 
may  not  seriously  impair  the  health,  yet,  after  a  time,  the  loss 
produces  a  marked  impression  on  the  system  ;  the  flow  lasting 
longer,  and  the  number  of  days  between  the  catamenial  periods 
being  so  diminished  that  scarcely  one  attack  is  over  before  another 
approaches.  Thus,  the  active  and  acute  variety  is  merged  in  the 
passive  form  of  the  disease." 


464  DISEASES     OF     TTOMEX. 

1009.  The  passive  form  of  menorrhagia  is    by  far    the  most 
frequent ;  it  varies  in  degree  from  a  slight  excess  over  the  normal 
discharge  to  a  profuse  and  rapidly  debilitating  hemorrhage.    Men- 
struation may  occur  at  the  regular  intervals,  or  these    may  be 
shortened,    the    menses    appearing   at   intervals  of  two  or  three 
weeks ;    the    length  of   the  menstrual  flow  may  also  be  greatly 
increased.     The  symptoms  are  those  of  exhaustion  and  debility  ; 
the   pulse   is  feeble,  and  occasionally  quickened,  the  extremities 
cold,  the  face  colorless,  want  of  appetite,  pain  and  Aveakness  of 
the  back,  indisposition  to  exercise,  etc.     This  variety  is  said  to  be 
almost  always  accompanied  with  leucorrhea. 

1010.  Another  species  of  menorrhagia  that  we  might  notice 
here,  occurs  at  the  commencement  and  close  of  menstruation,  and 
generally  results  merely  from  uterine  congestion.     In  the  young 
female  the  first  periods  of  menstruation  may  be  accompanied  by 
more  or  less  menorrhagia,  but  after  this  the  menstrual  function 
will  be  physiologically  performed,  still  the  loss  of  blood  at  these 
times  is  very  rarely  such  as  to  call  for  medical  interference.     It  is 
not  so,  however,  at  the  close  of  menstruation,  the  occurrence  of 
menorrhagia  at  this  time  being  both  frequent  and  profuse.     It 
may  arise  merely  from  uterine  congestion,  and  in  many  cases  this 
is  probably  the  cause ;  thus  the  menses  may  disappear  for  two  or 
three  periods,   and,  when  it  does  appear  again,  there  is  such  a 
determination    to    the    uterine    organs    that   menorrhagia   is   the 
result.     It  may  likewise  occur  at  this  period  from  the  presence 
of  malignant  growths,  and  tumors,  but  apart  from  these.  I  believe, 
it  is  most  frequently  caused  by  inflammation  either  of  the  entire 
uterus,   or  more   frequently  of  the    cervix.     On   this   point  Dr. 
Bennet  says  :  —  "In   nearly  all  the   instances   of  very  obstinate 
hemorrhage  at  the  change  of  life  which  I  meet  with,  I  find  on 
examination  that  the  congestion  and  hemorrhage  are  kept  up  by 
inflammation   and  ulcerative   disease.     Indeed,  some  of  the  very 
worst  instances  of  protracted  and  severe  hemorrhage  that  I  have 
ever  seen,  have  been  cases  of  this  description ;  and,  what  satisfac- 
torily proves  that  the  inflammatory  affection  is  the  cause  of  the 
continued  hemorrhage,  is,  that  when  it  is  cured  the  hemorrhage 
generally  ceases.     This  is  not,  however,  invariably  the  case.     I 


MEXOKRIIAGIA.  465 

have  occasionally  met  with  females  at  the  critical  period  of  life, 
in  whom  the  hemorrhage  obstinately  persisted  after  the  removal  of 
the  inflammatory  and  ulcerative  disease  of  the  cervix,  which  had 
probably  in  the  first  instance  given  rise  to  it.  In  several  of  these 
cases,  however,  time  or  dilatation  of  the  cervix  has  subsequently 
proved  that  the  hemorrhage  did  not  proceed  from  a  sound  uterus, 
but  was  connected  with  the  presence  of  a  polypus,  or  of  a  fibrous 
tumor,  so  small  and  obscurely  situated  as  not  to  have  been 
recognized  at  first." 

1011.  Causes. — The  causes  of  these  varieties  of  menorrhagia 
are  the  same  as  those  named  in  profuse  menstruation. 

1012.  Diagnosis. — The  fact   that    uterine   hemorrhage  exists 
can  always  be  ascertained  from  the  patient,  but,  whether  it  does 
or  does  not  arise  from   structural  disease  of  the  uterus,  can  only 
be  known  by  a  strict  vaginal  examination.     This  should  always  be 
made  if  the  hemorrhage  does  not  yield  to  the  use  of  the  ordinary 
remedies,  the  various  morbid  conditions,  capable  of  giving  rise  to 
uterine  hemorrhage,  have  been  already  described,  and  the  reader 
is  referred  to  them  for  their  distinctive  marks. 

1013.  Treatment. — In   active   hemorrhage  I   like  the  action  of 
Veratrum,  associated  with  Ipecac,  and  followed  by  oil  of  Erigeron 
if  necessary.     I  usually  prescribe — &  Tinct.  Veratrum,  gtt.  x.  to 
gtt.  xx.;  Tinct.  Ipecac,  gtt.  xv.;  Water,  siv.,  a  teaspoonful  every 
fifteen  minutes  at  first,  increasing  the  distance  between  the  doses 
when  the  patient  i'eels  nausea.     This  will  sometimes  be  all  that  is 
necessary,  with  rest  in  the   recumbent  position,  to  stop  the  most 
alarming   hemorrhage.     If  not,  follow  in  a  short  time  with  five- 
drop   doses  of  oil   of  Erigeron   on   sugar,  or   five-grain   doses  of 
Gallic  Acid.     In  place  of  Veratrum  the  Lycopus  maybe  given  in 
the  proportion  of  gtt.  xxx.  to  water  5iv.     Macrotyp  maybe  added 
to  the  treatment  when  there  is  muscular  pain  and  uterine  tender- 
ness, and  Viburnum  when  the  pain  is  expulsive  like  labor  pains. 
Apocynum  should  be  thought  of  when   there  is  the  slightest  ap- 
pearance of  oedema,  and  Ergot  if  there   is   impairment  of  spinal 
innervation.     The  Hamamelis  will  also  prove  a  A-aluable  remedy, 
and  should  be  thought  of  in  anticipating  the  next  menstrual  pe- 
riod.    It  maybe  given  in  teaspoonfnl  doses  during  the  flow,  and 

30 


466  DISEASES     OF     \VOMEN. 

afterwards  in  doses  of  one-fourth  teaspoonful  four  times  a  day. 
The  Senecio  and  Aletris  have  proven  useful  during  the  inter-men- 
strual period,  and  even  to  correct  the  hemorrhage.  If  the  hem- 
orrhage has  been  ushered  in  with  a  chill,  it  is  well  to  follow  the 
sedative  with  five-grain  doses  of  Quinine,  and  singular  as  it  may 
seem,  the  first  dose  will  sometimes  arrest  the  hemorrhage  when 
other  means  have  failed.  The  triple  phosphate  of  Quinia,  Strych- 
nia and  Iron,  in  the  usual  tonic  doses,  is  an  excellent  remedy 
during  the  inter-menstrual  period.  Should  the  hemorrhage 
be  alarming,  cold  may  be  applied  to  the  abdomen  and  vulva,  and 
the  vagina  plugged  with  sponge  or  linen  cloths.  During  the 
menstrual  interval  the  same  course  of  treatment  should  be  pursued 
as  recommended  for  profuse  menstruation  in  the  plethoric;  and 
should  there  be  any  inflammation  of  the  uterus  or  its  cervix, 
which  may  be  the  cause  of  this  form,  it  should  be  ascertained  and 
removed. 

1014.  In   passive  hemorrhage  we  may  give   the   Carbo-veg., 
oil  of  Erigeron,  Gallic  Acid,  tincture  of  oil  of  Cinnamon,  Apocy- 
num,  minute  doses  of  Ipecac  or  Ergot,  as  heretofore  recommended. 
I  like  the  action  of  the  first  named,   and  when  the  patient  was 
pallid  and  almost  bloodless,  I  would  rather  trust  it  than  any  other. 
The  Hamamelis  is  especially  the  remedy  Avhen  there  is  a  sense  of 
fullness  with  relaxation  in  the  pelvis  and  perineum.     The  patient 
should  be  kept  in  the  horizontal    position,    on    a   hard   bed    or 
mattress,  the  extremities  kept  warm  by  the  use  of  hot  bricks  or 
bottles  of  hot  water,  but  otherwise  she  should  be  kept  cool.     If 
the    above   measures  are  not  sufficient   to   arrest  the   discharge, 
Ergot  may  be  administered  in  doses  of  five  grains  and  repeated 
every  one  or  two  hours,  or   the    tampon  may  be  used,  or  the 
extremities  may  be  ligated  :  this  last  measure  will  nearly  always 
prove  effectual  in  checking  the  discharge  until  other  means  have 
had  sufficient  time  to  act. 

1015.  During  the  menstrual  interval  the  means  already  men- 
tioned should  be  resorted  to,  to  improve  the  general  health,  all 
causes  tending  to  produce  the  disease  should  be  avoided,  especially 
such  as  tend  to  produce  excitement  of  the  genital  organs.     The 
directions  of  Dr.  Ashwell  in  this  disease,  are  to  the  point.     He 


CHLOROSIS.  467 

days  :  "  Sexual  intercourse  and  stimulants,  mental  excitement  and 
physical  effort,  must  be  avoided  for  ten  or  twelve  days  before  the 
periodical  returns.  When  there  are  increasing  pallor,  oedema, 
threatened  dropsies,  softening  of  the  cervix,  and  aggravated 
debility — sea  air,  or  mild  but  nutritious  diet,  consisting  of  animal 
food  and  milk,  or  malt  liquor,  must  be  enjoined.  Where  there  is 
universal  coldness  of  surface,  especially  of  the  extremities,  fric- 
tions, by  stimulating  embrocations,  the  flesh-brush,  and  horse-hair 
gloves,  the  wearing  of  flannel  and  worsted  stockings,  arc  indi- 
cated. The  salt  hip-bath,  the  local  salt  shower-bath,  applied 
night  and  morning,  by  a  common  garden  watering-pot,  over  the 
hypogastric  and  lumbar  regions,  are  often  advantageous.  Xor  is 
the  injection  of  cold  water,  once  or  twice  a  day,  into  the  rectum, 
to  be  neglected.  Astringent  vaginal  injections  are  deservedly 
relied  on,  especially  if  carefully  administered  as  already  urged, ' 
during  the  intervals.  Still,  there  are  cases  where  cold  injections 
can  not  be  borne.  Local  fullness,  excitement,  and  pain  follow 
their  use  ;  and  sometimes  I  have  attributed  to  their  employment, 
an  earlier  and  larger  return  of  the  hemorrhage.  They  are  most 
beneficial  where  there  is  copious  leucorrhea,  and  from  the  cure  of 
this  morbid  •  secretion,  good  may  generally  be  anticipated.  It 
must  be  remembered,  that  the  unmarried  are  liable  to  congestive 
menorrhagia,  and  I  have  often  thought  that  their  cure  was  more 
difficult  and  protracted,  and  their  hemorrhages  larger,  than  where 
many  children  had  been  borne ;  but  on  this  point,  I  am  not  pre- 
pared to  give  a  positive  opinion." 

CHLOROSIS. 

1016.  Chlorosis,  or  green-sickness,  is  defined  by  Dr.  Ashwell, 
to  be :  "A  peculiar  affection  of  the  general  health ;  in  which 
'  debility,  languor,  and  deranged  stomachic  functions  are  prominent 
Symptoms  ;  most  frequently  occurring  when  puberty  is  or  ought 
to  be  established,  although  it  may  exist  at  any  subsequent  period, 
always  characterized  by  anaemia  of  the  system,  and  a  yellowish, 
dirty-green  pallor  of  the  surface.  When  a  disease  of  early 
youth,  almost  invariably  connected,  either  with  entire  absence  of 
menstruation,  or  with  a  scanty,  painful,  and  irregular  performance 


468  DISEASES     OF     WOMF.X. 

of  the  function  ;  and  if  a  disease  of  later  life,  in  addition  to  these 
causes,  it  may  have  been  preceded  and  produced  by  menorrhagia 
or  leucorrhea."  This  disease  is  strictly  a  disease  of  the  blood, 
and  may  arise  in  either  male  or  female ;  it  very  rarely  occurs  in 
males,  however,  and  when  developed  in  the  female,  it  is  nearly 
always  associated  with  some  derangement  of  the  menstrual  func- 
tion, hence  it  is  considered  by  most  authors  to  be  a  disease  either 
dependent  on  derangement  of  the  menstrual  functions,  or  else 
that  the  blood-disease  is  primary,  and  the  menstrual  derangement 
the  effect  of  it.  In  a  large  majority  of  cases,  it  occurs  at  or 
near  the  period  of  puberty,  and  it  has  thus  been  considered  a 
disease  peculiar  to  this  period. 

1017.  Pathology. — As  it  is  an  admitted  fact,  that  chlorosis  is  a 
disease  of  the  blood-mass,  we  have  to  ascertain  in  what  this  con- 
sists— what  change  the  blood  undergoes  to  produce  this  condition 
of  the  system,  and  then  what  influence  the  uterine  organs  have  in 
producing  this  change.  According  to  Becquerel  and  Rodier  the 
blood  of  a  healthy  female  consists  of  water  791.1  parts  in  1000, 
solid  constituents  208.9  parts  in  1000.  This  208.9  parts  of  solid 
constituents  consists  of:  fibrine  2.2,  corpuscles  127.2,  albumen 
70.5,  fat  1.6,  extractive  and  salts  of  serum  7.4.  In  chlorosis,  all 
the  constituents  of  the  blood  retain  their  normal  proportion,  with 
the  exception  of  the  red  globules,  which  are  diminished  from 
their  normal  amount  127.2  to  70.50,  or  even  as  low  as  27.  With 
this  diminution  in  the  red  globules,  we  may  have  a  diminution  in 
the  entire  quantity  of  the  blood — there  is  not  only  poor  blood 
(spanemia),  but  also  deficiency  of  the  blood  (anaemia).  Andral 
states :  "  That  the  quantity  of  blood  in  circulation  may  be  so 
diminished,  as  no  longer  to  penetrate  the  minute  vessels  of  the 
cutaneous  surface,  in  which  its  place  is  supplied  by  a  thin  serous 
fluid ;  and  after  death,  a  deficiency  or  even  total  absence  of  blood  * 
is  observed,  not  only  in  the  large  arteries,  veins  and  right  side  of 
the  heart,  but  likewise  in  the  capillary  system,  which  is  remark- 
ably pale  and  colorless.  In  these  cases,  the  membranous  and 
parenchymatous  tissues,  such  as  the  brain,  lungs,  liver,  kidneys, 
alimentary  canal,  and  the  parenchyma  of  the  heart  and  muscles, 
are  also  remarkably  pale  and  exsanguinous."  The  red  globules 


CHLOROSIS. 

of  the  blood  appear  to  be  that  part  on  which  its  vivifyino-  and 
calorific  properties  chiefly  depend.  This  is  proved  by  the  fact, 
that  when  they  exist  in  their  normal  proportion,  the  different 
functions  of  nutrition,  secretion  and  excretion,  are  all  normally 
performed ;  the  body  is  well  developed,  the  skin  reddened,  the 
color  of  the  blood  bright,  etc.;  while  in  persons  in  whom  they  are 
much  below  the  normal  standard,  the  functions  of  nutrition, 
secretion  and  excretion  arc  inactive,  the  surface  pale  or  sallow, 
the  muscles  flabby,  etc. 

1018.  We  have  now  to  examine  how  this  diminution  of  the  red 
globules  is  produced,  and  what  relation  the  uterine  system  has  to 
this  condition.  In  many  cases  of  chlorosis  it  has  been  observed, 
that  if  at  the  age  of  puberty  the  catamenia  did  not  become 
established,  or,  if  established,  that  it  had  become  suddenly 
checked,  that  the  health  began  to  deteriorate,  and  this  condition 
of  the  blood  was  produced.  ''  It  might  seem  difficult,"  says  Dr. 
Williams,  "  to  understand  how  irregularity  of  the  uterine  function 
operates  in  producing  this  condition.  That  in  many  cases  it  is  a 
cause,  and  not  an  effect  of  anaemia,  is  plain  from  the  well-known 
fact  that  no  signs  of  anaemia  have  occurred  until  cold,  over- 
exertion,  or  mental  excitement,  or  some  circumstance  has  suddenly 
checked  the  liow  of  the  catamenia ;  it  has  not  returned ;  and  then 
the  patient  bogins  to  lose  color,  and  gradually  to  exhibit  the 
anaemic  state.  In  many  cases,  I  have  known  this  to  occur  in 
young  females,  who  have  previously  suffered  from  acute  rheuma- 
tism, implicating  the  heart.  It  would  seem  that,  in  these  cases, 
some  injury  is  done  to  the  blood-particles,  and  to  the  powers  by 
which  they  are  repaired ;  this  is  manifest,  not  only  from  the 
pallidity,  but  from  the  yellowish  and  almost  greenish  hue  which 
the  complexion  sometimes  presents,  and  which  obviously  depends 
on  a  discoloration  of  the  textures  by  the  altered  blood,  as  in  the 
neighborhood  of  a  bruised  part.  In  some  of  these  cases  of 
chlorosis,  the  appetite  is  depraved ;  there  is  such  a  complete 
disrelish  for  animal  food  and  other  nourishing  articles,  and  such  a 
craving  for  sour  things,  and  even  for  matters  destitute  of  nourish- 
ment, as  chalk,  cinders,  etc.,  that  it  might  be  supposed  that  this 
perverted  appetite  is  the  cause  of  the  anaemia,  by  deterring  the 


470  DISEASES    OF    YTOMEX. 

patient  from  taking  that  food  which  is  capable  of  making  reel 
blood ;  and  undoubtedly  such  an  appetite,  when  indulged,  must 
contribute  to  this  result ;  but  it  is  not  so  constantly  present  as  to 
be  considered  the  chief  cause." 

1019.  Again,  the  disease  may  partly  depend  upon  a  lesion  of 
innervation,  the  uterus   and  ovaries  being   supplied   with  nerves 
from  the   sympathetic  system,  which   also   supply  the  organs  of 
digestion  and  sanguification ;   a  disease  of  the  uterus  and  ovaries 
will  affect  the  formation  of  the  blood  through  the  medium  of  the 
nerves.     That  this  is  the  case  in  structural  and  functional  disease 
of  these  organs  can  not  be  doubted,  for  in  almost  every  variety  of 
uterine    disease    we    find    that   the    digestive    organs    sympathize 
greatly  with  the  diseased  uterus  or  ovaries.     In  proof  that  this  is 
one    cause    of   the    malady,   Andral    states    that    "it   frequently 
happens,  that  by  stimulating  the  nervous  system  of  these  chlorotic 
patients  by  the  physical  and  moral  emotions  of  matrimony,  we 
produce    a   more    natural   complexion    and    color    of    the    whole 
cutaneous   surface,  thus  indicating  a   correspondent  improvement 
in  the  process  of  sanguification  ;  and  in  proportion  as  the  anaemia 
disappears   under  the   influence  of  this  new  modification  of  the 
nervous  system,  the  whole  train  of  diseased  action,  the  difficult 
respiration,    constant    sensation    of    uneasiness    and   listlessness, 
impaired   digestion,  gastralgia,  vomiting,  tympanitis,  and  limpid 
urine,  together  with   all   the    strange    nervous    symptoms,  which 
seemed    dependant    on    some    organic    alterations    of    the    solids, 
gradually   subside    and    eventually  vanish,    as   a  fresh   supply  of 
blood  is  generated  in  the  system. 

1020.  Causes. — The  causes  of  chlorosis  are  all  such  as  depress 
the  vital  powers  of  the  system ;  the  special  influence  of  derange- 
ment of  the  menstrual  function  has  already  been  noticed.     The 
primary  cause  of  the  menstrual  derangement,  and  thus  of  chlorosis, 
may  have  been  a  delicate,  feeble  state  of  the  constitution  from 
childhood,  the  vital  powers   not   being   sufficient,   to   perfect   the 
development  of  the  uterine  system  and  its  physiological  function, 
menstruation ;  this  may  again   react  in  the    manner  spoken   of, 
upon  the  general  health,  and  chlorosis  is  the  result.     It  may  also 
be  produced  by  any  exhausting  discharge,  as  menorrhagia,  profuse 


ciir.ouosis.  47} 

menstruation,  leucorrhea,  etc.  Or  by  insufficient  and  innutritious 
food,  crowded  and  ill-ventilated  apartments,  residence  in  a  damp 
cold,  or  marshy  locality,  etc. 

1021.  Symptoms. — The  symptoms  of  chlorosis  are  at  first  those 
of  debility;    the    patient   is   weak   and   languid,   dislikes   to   take 
exercise,  and  is  easily  fatigued ;  she  is  not  cheerful,  but  dull  and 
listless ;  there  is  a  habitual  melancholy  ;   she  loves  solitude,  and 
weeps   without   cause.     The   appetite  is  impaired  and  perverted, 
food  is  loathed,  and  innutritious  substances  desired,  as  chalk,  dirt, 
etc.     The   bowrels   are   nearly  always   constipated,    the   tongue  is 
coated   with  a  dirty  white   fur ;   there   is   flatulence,   arid   all  the 
symptoms   of   indigestion,   sometimes    tympanitis;    the   breath   is 
offensive ;     there    is    usually    more    or    less    frequent    headache, 
palpitation  of  the   heart ;    the    pulse    is    quick,   weak    and    com- 
pressible. 

1022.  In  the  aggravated  form  of  chlorosis,  says  Dr.  Ashwell, 
"Debility,  languor,  and  listlessness,  are  more  marked;  depression 
is  more  complete  ;  the  appetite  is  more  morbid,  with  a  desire  for 
slate-pencil,  chalk,  acids,  pickles,  and  other  things  equally  per- 
nicious.    The  complexion  becomes  still  more  characteristic:  it  is 
a  yellowish,  dirty  green,  and  the  lips,  gums,  conjunctiva,  and  the 
lining  membrane  of  the  mouth  are  bloodless ;  the  tongue,  too,  is 
of   a    still   paler   white,  and  being   soft   and  flabby,  it   is   easily 
indented  by  the  teeth;  the  breath  is  offensive;  there  is  nausea; 
sometimes  vomiting,  and  frequent  heartburn  ;  the  bowels,  though 
generally  constipated,  are  occasionally  in  a  state  of  irritable  and 
painful    diarrhea.       There    is    acute    and    anomalous    headache, 
attended  by  every  variety  of  distressing  sensation,  such  as  heavy 
weight  in  the  front  or  at  the  back  of  the  head,  vertigo,  fixed  and 
intense  pain  in  one  particular  spot,  paralytic  feeling  and  neuralgia. 
There  is  a  dark  line  underneath  the  eyes,  about  the  alae  of  the 
nostrils  and  at  the  angles  of  the  mouth  ;  the  eyelids  are  dark  and 
oedematous  in  the  morning ;  the  ankles  and  legs  are  frequently 
so  at  night;    the    cellular    or    soft    tissues    are    flaccid,   and    the 
surface  generally,  especially  of  the  upper  and  lower  extremities, 
is    cold.      If    menstruation    has    continued    up    to    this    time,  its 
intervals   become    more    distant,   the    discharge   itself  is   scanty 


472  DISEASES     OF     WOMEN. 

continuing  to  flow  only  for  a  few  hours,  and  in  quality  it  is  often 
serous  and  pale,  and  of  offensive  odor.  There  is  sometimes  a 
general  dryness  of  surface ;  the  skin  is  no  longer  resilient ;  there 

O  v 

is  a  splitting  and  brittleness  of  the  finger-nails ;  the  hair  loses  its 
glossy  brightness,  falls  off  in  large  quantities,  and  alters  in  color. 
It  is  not  uncommon  in  advanced  chlorosis,  for  the  abdomen  to  be 
full  and  painful ;  and  without  decided  phthisical  complication, 
there  may  be  slight,  short  cough,  pain  under  the  left  mammas,  and 
hysteria  in  a  variety  of  forms.  At  this  period,  one  or  several 
symptoms  being  confirmed,  so  far  mislead  as  to  induce  the  belief 
that  the  lung,  the  brain,  the  liver,  or  the  heart  may  be  organically 
diseased.  Such  is  the  malady  when  fully  developed." 

1023.  Treatment. — In  the  treatment  of  chlorosis  we  have  three 
prominent  indications  to  fulfil :  First,  to  remove  any  disease  which 
may  exist  independently  of  the   chlorotic   condition,   and  which 
may,  by  its  continuance,  tend  to  keep  it  up.     Second,  to  restore 
the  blood  to  its  normal  condition,  by  the  use  of  tonics  and  iron, 
nutritious  diet,   appropriate  exercise,   the  use  of  the  bath,  etc., 
and  Third,  to  stimulate  the  uterine  organs  to  a  performance  of 
their  natural  functions. 

1024.  Diseases   of    the    system    existing   in    connection   with 
chlorosis  will  have  to  be  treated  in  the  usual  manner,  having 
especial  reference,  however,  to  the  debilitated  condition  of  the 
system.    Two  of  these,  however,  deserve  special  notice :  disorders 
of  the  stomach  and  constipation  of  the  bowels,  or  what  is  of  rare 
occurrence — diarrhea.     We  have  already  seen  that  the  stomach  is 
the  first  organ  specially  affected  in  this  disorder,  that  the  appetite 
was  vitiated,  that  it  was  frequently  accompanied  with  nausea  and 
vomiting,  that  the  tongue  was  coated,  and  the  breath  offensive. 
As  a  healthy  condition  of  the  stomach  is  of  the  first  importance 
in  the  treatment  of  any  disease,  and  especially  of  this,  where  the 
entire  success  of  the  means  we  adopt  depend  upon  a  normal 
absorption  and  assimilation  of  the  remedies  given,  and  a  healthy 
performance  of  the  digestive  functions,  so  that  we  may  restore  the 
deficient  elements  of  the  blood ;   it  becomes  necessary  that  we 
have  some  definite  knowledge  of  the  condition  of  this  viscus  in 
chlorosis.     According  to  Dr.  Budd,  "the  continued  disturbance 


CHLOROSIS.  473 

of  the  secreting  function  of  the  stomach  seems  to  lead  to  an 
inflammatory,  or  u  catairhal  state  of  the  mucous  membrane. 
The  digestive  power  is  greatly  weakened,  and,  under  the  influence 
of  unhealthy  or  decomposing  mucus,  the  starchy  principles  of  the 
food  undergo  fermentation  in  the  stomach,  by  which  large  quanti- 
ties of  lactic  acid  arc  formed.  The  undue  acidity  of  the  stomach, 
or  the  great  disturbance  of  its  secreting  function,  lessens  the 
secretion  of  the  liver,  and  the  continuance  of  the  disorder  causes 
a  sallow  appearance  of  the  countenance."  In  many  cases  of 
chlorosis  this  condition  of  the  stomach  exists,  and  it  is  so  promi- 
nently marked  that  it  can  hardly  be  mistaken.  What  is  the 
remedy  for  this  condition  of  the  stomach  ?  Can  it  be  overcome 
by  the  use  of  tonics,  iron,  cathartics,  and  the  various  remedies 
recommended  for  chlorosis  ?  It  may ;  but,  in  my  opinion,  the 
easiest  and  surest  way  of  restoring  the  tone  of  the  stomach,  is  to 
first  remove  the  morbid  secretions  from  it  by  an  emetic,  which  will 
not  only  accomplish  this,  but  will  also  stimulate  the  stomach  to  a 
normal  performance  of  its  functions,  and  modify,  by  the  shock 
which  it  gives  to  the  system,  the  abnormal  nervous  irritability. 
I  may  be  wrong  in  estimating  the  proportion  of  cases  in  which 
this  condition  of  the  stomach  exists,  but  in  all  of  the  cases  that  I 
have  seen,  with  but  one  exception,  it  was  present.  My  use  of 
emetics,  in  such  cases,  commenced  as  a  dernier  resort ;  in  the  first 
case  I  had  employed  the  means  recommended  by  authors  for  the 
disease,  but  the  patient  gradually  declined  under  the  use  of  them, 
the  condition  of  the  stomach  was  evident,  and  I  determined,  not- 
withstanding her  weakness,  to  employ  an  emetic ;  the  Compound 
Powder  of  Lobelia  was  administered  in  infusion  in  the  usual  man- 
ner, accompanied  with  copious  draughts  of  warm  water,  free 
emesis  occurred,  and  the  quantity  of  decomposing  nauseous  mucus 
thrown  off  of  the  stomach  was  astonishing.  The  immediate 
benefit  derived  from  the  emetic  was  surprising,  at  least  it  surprised 
me,  as  I  was  fearful  of  the  result ;  in  a  few  hours  afterward,  the 
patient  expressed  a  desire  for  her  supper,  which  she  had  not  done 
for  three  months  before,  and  from  this  date,  under  the  influence 
of  mild  tonics,  the  soluble  preparations  of  iron,  nutritious  diet, 
.and  exercise,  she  rapidly  regained  her  health.  I  have  used  emetics 


474  DISEASES     OF     WOMEN. 

in  several  other  cases  of  debility  at  this  period  with  equal 
advantage ;  but  in  none  but  this  in  which  chlorosis  was  so  well 
marked.  The  only  account  of  the  use  of  emetics  in  this  disease 
that  I  have  seen  is  by  M.  Colombat.  He  says  :  "  Emetics,  first 
proposed  by  Mercatus,  (1554,)  may  be  appropriate  for  cases  in 
which  the  disease  is  complicated  with  some  gastric  disorder. 
Buillon  relates  that  all  the  remedies  employed  for  the  cure  of  the 
daughter  of  a  goldsmith,  aged  eighteen  years,  and  affected  with 
chlorosis,  proved  unsuccessful ;  but  he  adds  that  the  young  patient 
was  thrown  from  a  carriage,  which  gave  her  a  great  fright,  and 
brought  on  abundant  vomiting  of  bile ;  from  that  moment  her 
appetite  returned,  her  face  resumed  its  natural  color,  and  her 
health  was  perfectly  restored  in  a  short  time." 

1025.  Constipation  of  the  bowels  is  a  very  frequent  condition 
in  this  disease,  and  it  is  of  much  importance  that  it  should  be 
overcome ;  the  cause  of  the  constipation  is  probably  torpor  of  the 
bowels,  caused  by  deficient  innervation.     To  remove  this  difficulty, 
the  majority  of  authors  recommend  aloetic  purgatives — aloes  and 
some   of  the  preparations  of  iron.     But  a  much  better  remedy 
will  be  found  in  the  Compound  Tincture  of  Tamarac,  or  Bones' 
Bitters ;    this  may  be   given   in   doses  of  a  table  spoonful  three 
times   a  day,  half   an   hour  before  eating,  and  if   it    should    be 
necessary,   its    action   may  be    assisted   by  the   use    of  laxative 
enemas. 

1026.  Looking  back  over  the  experience  of  twenty  years,  I 
do  not  know  but  what  I  have  given  "  the  emetic  "  too  strong  a 
recommendation  and  too  wide  a  use;  and  yet  I  let  it  remain  as 
written  for  those  intractable  cases  with  foul  tongue  and  breath, 
that  will  not  yield  to  other  means.     In   some  cases  the  Sulphite 
of  Soda,  or  Sulphurous  Acid,  or  Chlorate  of  Potash,  will  rectify 
the  wrong  of  the  stomach.     In  others,  minute  doses   of  Podo- 
phyllin  with  Hydrastia  will  be  indicated.     Nux  Vomica,  and  Ig- 
natia  are  the  remedies  when  the  special  indications  of  nausea, 
sallow  expressionless  mouth    and    abdominal  pain,   or  morning 
chills,  cold  extremities,  and  peculiar  constrictive  pain  in  the  epi- 
gastrium, are  present.     Graphites,  Cuprum  and  Arsenic,  are  pos- 
sible remedies  in  these  cases,  the  indications  heretofore  given 


CHLOROSIS.  475 

prominent.  The  compound  Syrup  of  the  triple  phosphate 
of  Quinia,  Strychnin  and  Iron,  will  prove  a  good  tonic  and  resto- 
rative, when  there  is  an  indication  for  Quinine.  The  compound 
syrup  of  the  hypophosphites,  or  the  hypophosphite  of  lime,  when 
there  is  a  tendency  to  aplastic  deposits  in  cellular  tissue,  or  dis- 
ease of  the  lungs.  Our  indigenous  bitters  vary  in  their  medicinal 
action,  and  there  is  room  for  careful  observation  and  selection  of 
them  here.  I  would  especially  name  the  Senecio  and  Aletris  as 
worthy  of  trial. 

1027.  It  should  not  be  forgotten   that  chlorosis  is  dependent 
upon  or  associated  with  disease  of  the  reproductive  function  or 
organs,  and  this  should  be  carefully  looked  for.     Non-appearance 
of  the  menstrual  flow,  suppression,  and  menorrhagia,  may  all  be 
causes,  and  a  right  treatment  to  correct  these  wrongs  will  be  ab- 
solutely necessary  to  success.     Undue  sexual    excitement,  from 
any  cause,  may  prove  sufficient  to  produce  the  disease. 

1028.  In  regard  to  the  hygienic  treatment,  lean  not  do  better 
than   to  quote   from  M.   Colombat.     He   says :   "  Whatever   may 
have  been  the  cause  that   has  brought   on   chlorosis,   we   should 
remove  the  patient  from  all  exposure  to  cold  and  humidity ;  she 
should  breathe  a  dry,  pure  and   moderately  warm  air,  and  it  is 
because  these  conditions  exist  during  the  spring  and  autumn,  that 
those  seasons  are  most  favorable  to  the  cure  of  the   disease.     A 
dry,  breezy  situation,  in  a  sunny  exposure,  ought  to  be  recom- 
mended.    Clothes,  which  by  the  nature  of  their  tissue,  slightly 
irritate  the  skin,  are  to  be  preferred  to  any  others.     Flannel  worn 
next  to  the  skin,  and  especially  alcoholic  and  aromatic  frictions  to 
the  whole  surface  of  the  body,  should  likewise  be  proposed,  with 
the  view  of  exciting  the  action  of  the  capillary  vessels,  of  invit- 
ing the  blood  into  them,  and  promoting  perspiration.     The  food 
must  consist  of  roast  meats,  fresh  eggs,  farinaceous  vegetables, 
ripe  fruits,  and  bitter  and  aromatic  plants ;  for  example,  succory 
and    celery.     As   a   drink   during  meals,   we   may    employ   with 
advantage,   a  mixture  of  chalybeate  water  with  wine.     Between 
the  repasts,  the  patient  may  allay  her  thirst  with  some  refreshing, 
slightly  acidulated  drink.     Nevertheless,  though  a  careful  regimen 
ought  to  be  strictly  observed,  it  is  not  well  to  be   too  exclusive; 
if   we  meet  with  great  reluctance   in    giving    up    the    injurious 


476  DISEASES      OF      AVOMEX. 

articles  which  the  patients  desire,  it  would  be  necessary  at  first, 
to  respect  their  longings,  however  strange  they  might  seem,  and 
even  to  satisfy  them,  unless  they  were  directed  to  substances 
evidently  hurtful.  We  should  always  commence  by  regulating 
the  meals,  and  by  forbidding  fruit,  salad  and  all  crude  articles  ; 
we  ought,  moreover,  to  consult  the  digestive  functions,  and  wholly 
proscribe  articles  well  known  to  be  indigestible. 

1029.  "  Whatever  be  the  aversion  to  exercise  felt  by  chlorotic 
persons,  we  ought  invariably  to  insist  upon  its  employment,  regu- 
lating it,  however,  by  the  strength  of  the  patient.     Should   the 
muscular  debility  be  so  great  as  to  prevent  her  from  walking,  we 
must  resort  to  mixed  and  passive  exercises.    Riding  in  a  carriage, 
or  still  better,  on  horseback,  especially  if  a  man's  saddle  is  used, 
in  open  and  elevated  places,  where  the  air  is   pure,  are   proper 
modes  of   exercise,  particularly  if  pleasant  conversation  can  be 
added  to  the  charms  afforded  by  diversity  of  views  and  landscapes. 
Boating  excursions,  which  exert  a  favorable  effect  upon  all  the 
organs,  and  which  unite  to  all  the  advantages  of  exercise,  that  of 
being  agreeable   to   young  persons,   and   of   producing   a  useful 
stimulation  by  the  presence  of  individuals  of  the  opposite  sex ; 
music,  which  occasions  a  salutary  excitation  in  lymphatic  persons, 
and   finally,  sea-bathing,  and   swimming  in  running    water,    are 
different  hygienic  means,  which  it  is  well  to  recommend  to  ner- 
vous, sad  and  melancholy  women,  and  to   those  of  great  moral 
sensibility.     Traveling  can  not  be  too   strongly   recommended  to 
persons  in  whom  the  disease  is  kept  up  by  acute  sorrow,  or  by  any 
moral  affection  whatever ;  the  use  of  mineral  waters  taken  at  the 
springs,  offers  in  this  respect,  incalculable  advantages,  not  only 
from  the  medicinal   action   of   the  waters   themselves,   but   also, 
because  the  patients  enjoy  at  such  places  the  various  charms  of  a 
numerous  and  brilliant  society,  and  attractions  Avhich  are  con- 
stantly changing. 

1030.  "  The  use  of  very  tight  corsets  ought  to  be  forbidden  ; 
sleep  should  not  be  protracted  beyond  eight  or  nine  hours,  and 
care  must  be  taken  that  the  patient's  bed  is  neither  too  warm  nor 
too  soft,  because  such  beds  often  increase  the  feebleness  and  con- 
stipation of  very  sensitive  women,  especially  those  in  whom  the 


HYSTERIA.  477 

chlorotic  state  has  been  developed  and  maintained  under  tlie 
influence  of  disappointed  love.  We  should  forbid  exciting  drinks, 
wine,  highly  nutricious  food,  vivid  emotions,  the  frequenting  of 
balls  and  shows,  the  reading  of  highly-wrought  romances,  the 
examination  of  lascivious  pictures,  and  lastly,  we  should,  as  far 
as  possible,  suppress  all  circumstances  capable  of  disturbing  the 
sensibility,  or  of  exciting  the  passions  too  strongly." 

HYSTERIA. 

1031.  By  the  term  hysteria,  we  understand  a  peculiar  nervous 
affection  not  entirely  confined  to  females,  but  in  a  large  majority 
of  cases  seen  in  them,  and  generally  the  result  of  some  structural 
or  functional  disease   of  the  uterine   organs.     Dr.   Condie   states 
that  be  "  has  repeatedly  seen  all  the  phenomena  characteristic  of 
hysteria  in  the   male   subject.     The  fact  of  their   recurrence   in 
males  is    also  stated   by   Sydenham,  Louyr,  Yillermay,   Georget, 
Ferriar,  Frotten,  Conolly,  and  others."     We  have  to  consider  it, 
however,  only  as  it  occurs  in  females. 

1032.  Pathology. — Various    opinions    have    been   advanced  in 
regard  to  the  pathology  of  hysteria,  and  yet  none  of  them  appear 
so  reasonable   as  the  most   ancient  one,  that  it  arises  from  some 
disease   of  the  uterine   system.     If  we  examine  the  anatomy  of 
the   uterus   and    its    appendages,   we   find  that  it  is   abundantly 
supplied  with  nerves  from  the  hypogastric  plexus  of  the  sympa- 
thetic,  and  from  the   spermatic   or   ovarian  plexus   of  the   same 
system.     It  will  also  be  noticed  that  the  hypogastric  plexus  is  not 
formed  solely  by  branches  from  the  sympathetic  system,  but  that 
it  likewise    receives    numerous    small    branches    from  the    spinal 
nerves,  and  thus  a  connection  is  formed  between  the  uterus  and 
spinal   cord.     As  the    uterine    organs    receive    nerves    from    the 
sympathetic  system,  which  also  supplies  the  organs  of  digestion, 
sanguification,  and   secretion,  it  is  evident  that  disease   affecting 
the  uterus  will  also  affect  more  or  less  the  entire  portion  of  the 
system   supplied  with  those   nerves,  by  sympathy.     This  fact  is 
well  proved   in    almost    all    diseases    of   the    uterine  organs,  the 
disease  affecting  in  a  marked  degree  the  functions  of  digestion, 
assimilation,  secretion,  and  excretion.     The  intimate  connectioa 


478  DISEASES     OF     WOMEX. 

existing  between  the  uterus  and  ovaries,  through  the  medium  of 
the  nerves  connecting  the  sympathetic  system  and  the  cerebro- 
spinal,  and  through  the  branches  of  the  spinal  nerves  which  pass 
through  the  hypogastric  plexus  to  these  organs,  will  account 
anatomically  in  part  for  the  nervous  irritability  that  is  manifested. 
Dr.  Carpenter  says  :  *'  The  clinical  history  of  hysteria  would  lead 
us  to  suppose  that  the  convulsive  action  depends  rather  upon  some 
state  of  the  blood  which  alters  its  relation  to  the  nervous  tissue, 
as  its  exciting  fluid,  than  upon  any  change  in  the  nutritive  supply 
which  it  affords  as  would  induce  a  more  permanent  disorder  in  the 
system.  Taking  all  the  phenomena  into  account,  there  seems 
much  reason  to  think  that  a  general  excitability  of  the  nervous 
system,  such  as  is  only  an  exaggeration  of  that  which  is  charac- 
teristic of  the  female  sex,  is  induced  by  some  defect  of  nutrition, 
comparatively  permanent  in  its  nature."  This  defect  of  nutrition 
may  occur  in  two  ways ;  first,  through  nervous  sympathy,  as 
already  mentioned,  and  second,  through  the  circulation.  It  is 
supposed,  and  with  much  plausibility,  that  the  constitution  of  the 
blood  is  affected  by  the  condition  of  every  tissue  with  which  it 
comes  in  contact,  so  that  if  any  diseased  condition  of  the  uterus 
exists,  the  circulation  of  blood  through  that  organ,  will  change 
the  condition  of  the  entire  circulating  fluid. 

1033.  Symptoms. — I  can  not  do  better  than  to  give  the  symp- 
toms of  this  singular  and  ever-varying  malady  as  they  are 
described  by  Newton  and  Powell. 

"  Most  of  the  disquieting  feelings,  strange  and  wayward  fancies 
of  nervous  females  arise  from  hysteria.  A  paroxysm  is  usually 
preceded  by  general  uneasiness,  anxiety  and  oppression ;  a  sensa- 
tion of  choking,  or  as  if  a  ball  were  rising  up  from  the  abdomen 
into  the  throat,  to  which  sensation  the  appellation  of  globus  hysteri- 
cus  has  been  given  ;  stiffness  about  the  larynx,  headache  and 
cramps.  M.  George  says :  '  Hysteric  patients  in  the  hospital  of 
the  Salpetriere,  are  so  well  accustomed  to  take  warning  by  these 
precursory  symptoms,  as  never  to  be  seized  unexpectedly  ;  they 
go  to  bed,  and  are  tied  down  until  the  fit  is  over.'  Sometimes 
the  paroxysm  ends  here ;  but  more  generally  the  anxiety  and 
sufferings  increase,  extreme  depression  of  spirits,  often  weeping. 


HYSTERIA.  479 

ensues ;  there  is  a  painful  sense  of  stiffness  and  coldness  of  the 
limhs ;  noise  in  the  ears ;  vertigo ;  confusion,  and  to  these  rapidly 
succeed  temporary  loss  of  sense  and  consciousness,  and  of  com- 
mand over  the  voluntary  muscles,  during  which,  the  most  vehement 
struggles  are  alternated  with  moments  of  repose.  Occasionally, 
there  is  a  tetanic  rigidity  of  the  muscles  of  the  trunk  or  back, 
and  the  body  is  thrown  up  in  the  form  of  an  arch,  but  the  limbs 
are  more  generally  contorted  ;  the  patient  often  beats  her  breast, 
tears  her  hair,  grinds  the  teeth,  bites  the  tongue  or  lips,  or  other- 
wise injures  herself.  The  assistants  are  often  struck,  bitten  or 
scratched,  and  have  vociferous  epithets  heaped  on  them  ;  terrific 
screaming,  sobbing,  laughing  and  vacant  staring  may  rapidly  suc- 
ceed each  other.  During  the  struggling,  the  heart  beats  tumultu- 
ously,  the  countenance  becomes  flushed  and  swollen,  and  the 
breathing  laborious.  After  a  variable  continuance  of  from  a  few 
minutes  to  some  hours  or  even  days,  of  repeated  intervals  of 
struggling  and  repose,  as  here  described,  the  patient  either  falls 
asleep  or  gradually  returns  to  a  state  of  consciousness  and  her 
ordinary  condition,  save  feelings  of  fatigue  and  soreness,  which 
disappear  in  a  few  days.  Such  are  the  prominent  features  of  the 
hysteric  paroxysm  ;  but  it  varies  greatly  in  intensity  and  duration. 
The  convulsions  may  be  severe,  with  lucid  intervals,  and  of  fre- 
quent occurrence  for  days,  or  a  deep,  quiet  sleep  or  coma  may 
fill  up  the  intervals,  from  which  nothing  can  arouse  the  patient. 
In  some  women,  the  paroxysms  return  monthly,  or  at  the  men- 
strual flow ;  in  others,  at  variable  intervals  dependent  on  disturb- 
ances of  the  physical  or  mental  equability.  It  is  remarkable  that 
plumpness  of  person,  roseate  hue  of  countenance,  and  general 
appearance  of  good  health  are  not  incompatible,  but  often  attend 
the  worst  of  sufferers  from  this  affection  through  life,  so  faithfully 
is  the  nutritive  function  preserved  amid  the  many  and  frequent 
storms  of  nervous  functional  derangement. 

1034.  "  So  variable  are  the  protean  shapes  which  hysteria  may 
assume,  that  there  is  scarcely  an  organ  or  its  function  that  may 
not  be  invaded  and  the  gravest  maladies  counterfeited,  calculated 
to  lead  to  errors  in  diagnosis  and  prognosis,  compromising,  if  not 


480  DISEASES      OF      WOMEN". 

the  life  and  welfare  of  the  patient,  at  least  the  reputation  for  close 
discernment  of  the  practitioner. 

1035.  "  Sudden,    extreme,    and    anomalous    symptoms    should 
not  be   hastily  pronounced  upon  at  the  bedside  of  the  patient. 
Hysteric  distention  of  the  intestines  by  flatus  has  been  mistaken 
for  pregnancy ;  hysteric  hiccup,  for  that  of  approaching  death ; 
hysteric  colic,  for  acute  peritonitis ;  hysteric  stridulous  breathing, 
for   croup ;  hysteric  cough,  for  hooping-cough ;    hysteric  limpid 
urine,    for    diabetes;    intense    urinary    irritation,    for    nephritis; 
interior  irritation,  for  inflammation ;  hysteric  headache,  for  ence- 
phalitis ;  hysteric  tenderness  and  swelling  of  the  knee-joint,  for 
white  swelling ;  hysteric  coma,  for  apoplexy ;  hysteric  wayward- 
ness, for  mania,  etc. 

1036.  "  Diagnosis. — The  suddenness  of  an  attack  of  epilepsy, 
the  cry,  the  fall,  the   distortion  of  the  features,  frothing  at  the 
mouth,    livid    turgescence    of    the    face,    small    quantity    of    air 
admitted  in  inspiration,  and  the  profound  coma  are  sufficient  to 
distinguish  it  from  the  hysteric  paroxysm  which  certainly  similates 
epilepsy  more  than  any  other  affection.     The  want  of  correspon- 
dence  between  the   violence   of   functional    disturbance  and    the 
symptoms  of  organic  disease  will  generally  guide  in  distinguishing 
hysteric  imitations  or  counterfeits.     The  history  of  the  individual 
will  aid ;  examination  of  the  spine  also. 

1037.  "  Causes. — Whatever  impairs   the    constitution   and  in- 
creases the  excitability  of  the  nervous  system,  may  become  an 
exciting  cause  of  hysteria.     The  anemic  state  favors  its  incursion; 
an  irritable  habit  produced  by  errors  in  early  physical  training : 
early    vicious    practices ;     emotional    and    imaginative    reading ; 
spinal,    uterine,  or   gastric    irritation;    strong    and   impassioned 
feelings  ;  startling  sights,  sounds,  or  intelligence  ;  grief,  jealousy, 
or  unrequited   love.     The   ancient  doctrine  was  that  the  uterus 
was  the  seat  of  the  disease,  but  modern  physicians  regard  it  as 
seated  in  the  nervous  system  or  centers." 

1038.  Treatment. — The  treatment  of  hysteria  will  be  of  two 
kinds :  palliative  treatment  while  the  paroxysm  is  on,  and  treat- 
ment for  the  radical  cure  of  the  affection  by  removing  any  uterine 


HYSTERIA.  481 

disease    that    exists ;     strengthening    the    digestive    organs,    and 
restoring  the  general  health. 

1039.  If  called  to  see  a  patient  suffering  under  an  attack  of 
hysteria,  it  is  recommended  to  administer  anti-spasmodics,  as 
Assafoetida,  Valerian,  Musk,  Castor,  Scutellaria,  etc.  These 
agents  may  prove  very  efficient  at  times,  but  I  have  never  had 
any  success  with  them.  I  have  used  the  Tincture  of  Gelseminum, 
in  all  cases  marked  by  flushed  face,  bright  eyes,  and  contracted 
pupils — the  dose  of  our  strong  tincture  being  five  drops  eveiy 
fifteen  to  thirty  minutes  until  the  patient,  in  relieved.  The  tinc- 
ture of  Lobelia  and  Capsicum  is  the  remedy  when  the  pulse  is 
oppressed  and  feeble,  half-teaspoonful  every  ten  or  fifteen  minutes, 
until  it  nauseates  the  patient,  or  produces  vomiting,  and  I  have 
found  in  every  instance  that  nausea  or  vomiting  and  hysteria 
were  incompatibles.  There  can  be  no  doubt  that  impressions 
produced  upon  the  mind  have  great  influence  in  checking  these 
paroxysms  or  in  keeping  them  off,  and  the  Lobelia  and  Capsicum 
will  be  found  to  produce  such  a  disagreeable  impression  on  the 
patient,  that  rather  than  experience  the  effects  of  the  medicine, 
if  she  is  certain  that  it  will  be  given,  she  Avill  resist,  and  that 
successfully,  the  approach  of  the  paroxysm  ;  at  least  this  has  been 
my  experience.  Sometimes  it  will  be  impossible  to  administer 
anything,  on  account  of  the  spasmodic  closure  of  the  jaws,  but 
the  medicine  can'  generally  be  introduced  into  the  corner  of  the 
mouth  ;  if  it  can  not  be  given  this  way,  it  may  be  injected  into  the 
rectum,  using  double  the  quantity  of  the  medicine  that  would  be 
given  by  the  mouth.  Sir  Charles  Clark  recommended  strongly 
the  cold  water  douche ;  bringing  the  patient's  head  to  the  edge  of 
the  bed,  he  would  pour  on  pitchersfull  of  cold  water,  until  the 
paroxysms  had  ceased.  In  one  case  related  by  Dr.  Watson,  of  a 
young  lady,  who  for  many  days  had  been  affected  by  trismus,  so 
that  she  was  unable  to  open  her  jaws,  and  could  therefore  neither 
speak  nor  eat,  this  treatment  was  adopted.  Sir  C.  Clark  being 
called  in,  recognized  the  nature  of  the  affection.  He  had  her 
placed  with  her  head  hanging  over  a  tub  by  the  side  of  the  bed, 
and  proceeded  to  pour  pitchers  of  cold  water  on  her  face.  Before 
he  had  emptied  the  second,  the  patient  could  scream  and  com- 
81 


482  DISEASES     OF     WOMEN. 

plain,  giving  very  audible  indications  that  she  could  open  her 
mouth.  Dr.  Watson  says,  "Although  these  patients  get  great 
relief  by  the  treatment,  they  do  not  like  it ;  and  if  they  are  con- 
vinced that  it  will  be  put  in  force,  they  will  generally  manage  not 
to  require  it." 

1040.  The  treatment  after  the  paroxysms  are  over,  must  be 
conducted  on  general  principles,  any  disease  of  the  uterine  organs 
existing  must  be  removed,  and  the  general  health  restored  in  the 
manner  heretofore  pointed  out.  In  reference  to  the  preventive 
treatment,  Dr.  Ashwell  makes  the  following  judicious  remarks  : 
"  Where  a  tendency  to  the  disease  is  evident,  or  where  one  or 
several  decided  hysteric  seizures  have  occurred,  it  is  evident  that 
every  prophylactic  measure  should  be  early  and  fully  adopted.  The 
remarks  on  the  physical  education  of  female  youth  already  made, 
have  a  distinct  reference  to  this  important  subject,  and  it  can  not 
be  too  strongly  urged,  that  nature  and  common  sense  are  the  best 
arbiters  in  every  matter  relative  to  female  health.  Of  all  the 
influences  capable  of  molding  the  female  constitution,  there  are 
none  so  powerful  as  light,  air,  food,  and  exercise',  and  certainly, 
in  reference  to  the  two  latter,  nothing  can  be  more  at  variance 
with  propriety  than  our  modern  customs.  It  were  easy  to  censure 
the  way  in  which  female  education  is  conducted,  but  it  would  be 
to  little  purpose,  till  such  plans  are  adopted  as  shall  insure  a 
higher  appreciation  of  physical  health  and  vigor.  Happily  of  late 
some  degree  of  reformation  is  observable ;  and  the  young  ladies 
in  our  fashionable  boarding-schools  are  beginning  to  realize  its 
blessings.  Animal  food,  and  not  farinacious  puddings  and  slops ; 
wholesome  malt  liquor,  instead  of  water,  tea,  or  bad  wine ;  run- 
ning, jumping,  and  vigorous  play,  are  more  occasionally  heard 
of  without  being  condemned  as  fit  only  for  the  vulgar.  By  and 
by,  it  is  to  be  hoped,  that  a  sounder  education  will  be  built  on 
these  natural  principles ;  and  instead  of  days  and  weeks  devoted, 
as  they  now  are,  to  music,  absurd  accomplishments,  and  romantic 
nonsense,  some  hours,  at  least,  daily,  or  weekly,  will  be  given  up 
to  history,  general  literature,  and  the  economy  of  every-day  life." 


DISEASES     OF     THE     BREAST.  433 


CHAPTER     XV. 


DISEASES   OF    THE   FEMALE   BREASTS. 


BY  PROF.  R.  S.  NEWTON. 


1041.  The  space  allowed  to  me  precludes  the  idea  that  I  should 
-enter  into    a  minute   description   of  the  minor  affections  of  the 
female  mammas.     It  is  to  those  more  terrible  forms  of  disease  of 
the  breasts  that  I  would  call  attention.     There  have  been  written 
many  very  excellent  and  learned  dissertations   on   the   subject  in 
hand,  and  at  a  first  thought  it  would  seem  that  nothing  had  been 
left  unsaid  'which  could  throw  light  on  the   subject ;  yet  all  these 
fine  essays,  all  the  deep  research,  all  the  experiments  and  statistics 
of  the  books,  in  a  practical  point  of  view,  amount  to  but  little. 
Physicians,  with  all  their  skill,  and  with  a  perfect  knowledge  of 
the  experience  and  opinions  of  others,  who  have  written  on  this 
•class  of  diseases,  still  have  to  endure  the  mortifying  spectacle  of 
the  unchecked  ravages  of  such  affections,  and  their  own  inability 
to  arrest  their  progress.     It  matters  little  whether  we  are  able  to 
give  the  rationale  of  the  cure  or  not,  if  any  one  really  can  affect 
a  cure  of  a  reasonable  proportion  of  the  more  malignant  forms  of 
disease,  to  which  the  female  breast  is  liable,  he  will  have  done 
more  for  humanity  than  all  the  learned  essayists  who  have  written 
on  the  subject. 

1042.  Having  made  this  class  of  diseases  a  special  study  during 
the  past  sixteen  years,  and  having  had  extensive  opportunities  to 
investigate  the   subject,  I  deem   it   my  duty  to   offer  to   the  pro- 
fession my  opinions,  which,  in  many  respects,  will  not  differ  from 
views  advanced  by  others,  but  in  other  particulars  the  divergence 
will  be  very  material.     One  of  the  simplest  divisions  of  diseases 
of  the  breast  is  that  of  Mr.  Syme,  viz. : 

1.  Those  in  which  there  is  merely  derangement  of  its  nutritive  or 
sensitive  action,  causing  simple  enlargement,  induration,  and  pain ; 


484  DISEASES     OF     W  0  M  E  X  . 

2.  Those  in  which  there  is  a  collection  of  purulent  fluid ; 

3.  Those  in  which  there  is  a  morbid  growth,  limited  to  the  part 
in  which  it  originates  ;  and 

4.  Those  in  which  the  growth  is  of  a  malignant  kind, — that  is, 
tends  to   spread,   ulcerate,    or   fungate,  and  affect  the  patient's 
constitution. 

1043.  But  to  comprehend  the  nature  of  the  diseases  to  which 
the  mammae  are  subject,  we  must  understand  their  structure  and 
functions.     So  far   as  its   anatomy  is   concerned,  we  may  learn 
something   of  its   complicity  from   the   statement  of   Sir  Astley 
Cooper,  that  he  had  heard  a  good  anatomist  say,  "  The  breast  is 
so  complicated  that  I  can  make  nothing  of  it." 

1044.  The  breasts  are  situated  on  the  anterior  portion  of  the 
chest,  upon  the  lower  part  of  the  platysma  myoides  muscle,  upon 
the  anterior  portion  of   the  pectoralis  major,   upon  the   serratus 
major  anticus  and  oblique  externus  abdominis.  and  usually  cover 
the   space  from   the   third  to   the   seventh  rib.     The   breasts  are 
essentially  glands,  and,  when  well  developed,  constitute  the  most 
beautiful  apparatus  in  the  body.     In  location  and  number  they 
differ  in  different  classes  of  animals,  there  being  generally  two  for 
each  young  one  to  be  nourished  by  their  milk.     It  has  been  often 
supposed,  that  the  provision  of  a  pair  of  breasts,  as  in  the  human 
female,  was  a  provision  of  nature  to  supply  nourishment  for  twins, 
when  accidentally  produced.     This  seems  not  to  be  the  case,  but  to 
correspond    with    that    common  duplication    of    our    organs,  the 
natural  provision  for  disease.     If  one  eye  is  diseased,  the  other 
may  serve  the  purposes  of  sight,  and  so,  if  one  breast  shall  be  the 
seat  of  disease — a  very  common  occurrence — then  the  sound  one 
will  answer  all  the  purposes  for  which  the  apparatus  is  intended. 

1045.  These  glands  are  not  situated  on  the  chest  so  as  to  pro- 
ject the  nipples  directly  forward,  but  rather  laterally,  so  as  to 
make  the  projecting  nipple  more  convenient  to  the  mouth  of  the 
child.      Sir  Astley    Cooper   has  written   very    elegantly    of   the 
adaptedness  of  the  breast  to  the  convenience  of  the  child,  and  I 
would  suggest  to  the  student  a  careful  examination  of  the  subject, 
as  he  will  be  more  likely  to  detect  even  a  slight  variation  from  the 
normal  position,  and  which  will  enable  him   to   escape   errors  in 


DISEASES     OE     THE     BREAST.  48-J 

-diagnosis.  It  is  quite  true  that  in  those  who  have  borne  and 
nursed  many  children,  the  gland  becomes  pendulous,  and  the  nipple 
may  project  forward  without  any  disease  being  present.  And  in 
some  tribes,  as  the  woman  of  South  Africa,  etc.,  this  elongation 
and  relaxtion  of  tissue  is  so  great  that  the  breast  may  be,  and  is 
often,  thrown  over  the  shoulder,  that  the  child  may  nurse  as  it  is 
carried  on  the  back  of  its  mother. 

1046.  When  viewed  as  a  mass,  the  mammary  gland  is  a  coni- 
form body,  somewhat  globular,  with  its  base  rather  cupped  to  fit 
the  bend  of  the  ribs.     The  number  in  the  human  female  is  usually 
two,  but   cases   have  been  recorded   in  which   there  were  four,  as 
was  the  case  of  a  very   respectable  mother   seen   by  Dr.  Robert 
Lee  and  Sir  Astley  Cooper.     [Cooper  on  the  Breast,  pp.  25  and 
26.]    But  such  cases  are  to  be  regarded  as  accidental  developments. 
The  mammary  gland,  in  its   structure,  is   not   unlike   that   of  the 
salivary  and  parotid  glands,  though  on  a  more  magnificent  scale. 
It  is  made  up  of  from  fifteen  to  thirty  lobes,  varying  in  size  from 
one-fourth  to  one  inch  in  diameter,  the  size  being  greater  as  we 
approach  the  base  of  the  gland.     The  lobes  are  again  divided  into 
smaller  compartments,  called  lobules,  and  these  again   are  sub- 
divided into  coecal  vesicles.    The  ducts  of  excretion  are  thoroughly 
lined  with  a  beautiful  tessellated  epithelium  ;    they  all  converge 
toward  the  nipple,  upon  which  they  open  by  a  number  of  small 
apertures,  ranging  in  number  from  ten  to  twenty.    In  their  course 
they  dilate  into  small  ampulse,  which  vary  in  capacity. 

1047.  The  breast  is  divided  anatomically  into  two  parts,  the 
internal  and  the  external,  both  of  which  require  careful  study.    Per- 
haps the  true  way  to  get  a  knowledge  of  the  gland  is  to  begin  at  its 
development,  and  end  by  giving  its  physiology.     The  mammary 
gland  originates  from  the  mucous  layer  of  the  epidermis,  as  a 
mere  papillary  projection,  as  early  as  the  fourth  or  fifth  month  of 
foetal  life.     It  soon  develops  into  a  complicated  glandular  struc- 
ture, very  irregular  at  first,  but  which  acquires  symmetry  as  birth 
approaches.     All  its  parts  converge  to  form  the  mammilla,  or  nip- 
ple, which  is  not,  as  is  supposed  by  many,  in  the  center  of  the 
glandular  body,  but  nearest  the  abdominal  margin,  and  also  nearer 
the  posterior  than  the  anterior  margin.     Or,  as  Sir  Astley  Cooper 


4S6  DISEASES     OF     WOMEAT. 

says :  "  from  one-half  to  three-quarters  of  an  inch  above  the 
lower  edge  of  the  pectoralis  major."  The  lactiferous  canals, 
which  are  thrown  nearly  together  in  the  virgin,  separate  and 
enlarge  in  the  lactating  woman,  and  hence  the  nipple  is  increased 
in  size,  in  such  as  have  nursed.  It  is  also  longer,  and  can  never 
after  be  made  to  acquire  the  solidity  of  the  virgin  state.  Imme- 
diately on  the  apex  of  the  nipple,  there  is  a  small  indentation, 
caused  by  the  orifices  of  the  lactiferous  tubes.  Before  puberty 
the  nipple  is  quite  smooth,  but  it  is  afterward  masked  by  small 
papillae,  which  increase  in  size  up  to  forty  years  of  age.  It 
acquires  a  wrinkled  aspect  after  the  age  of  fifty,  and  in  old 
women  has  a  warty  appearance.  The  shape  of  the  nipple  is 
sometimes,  but  not  always,  changed  by  nursing;  in  the  virgin,  it 
is  a  rounded  cone,  with  the  base  or  broad  part  resting  on  the 
breast,  but  in  women  who  have  nursed  many  children,  their  order 
is  reversed,  or  else  occupies  some  medium  place  between  the  vir- 
gin state  and  the  last-named  condition.  Its  color  is  very  various, 
passing  through  all  the  shades  of  red,  and  is  often  even  of  a  very 
dark  muddy  color ;  generally,  however,  it  loses  much  of  its  color 
as  old  age  advances,  and  during  utero-gestation,  is  possessed  of 
a  higher  color  than  at  other  times.  I  desire  to  be  minute  in  the 
description  of  the  various  parts  of  this  gland,  for  no  one  is  com- 
petent to  judge  of  its  pathological  states,  until  he  is  well  ac- 
quainted with  its  entire  structure. 

1048.  In  respect  to  the  cuticle  covering  the  gland,  I  need  only 
notice  that  it  is  much  more  thin  and  delicate  in  women  with  fair 
skins  and  red  hair,  and  is  hence  more  apt  to  be  abraded  by  the 
mouth  of  the  child.     The  nipple  is  generally  darker  than  the  rest 
of  the  breast,  which  is  owing  to  the  rete  mucosum,  the  character 
of  which  will  be  more  fully  explained  presently. 

1049.  The  areola  or  colored  circle  of  skin  which  surrounds  the 
nipple,  has  received  a  large  share  of  attention,  and  as  I  deem  an 
acquaintance  with  its  characteristics  of  considerable  importance, 
I  shall  feel  warranted  in  also  referring  to  it,  at  least  briefly.     The 
areola  is  but  a  spreading  of  the  nipple,  or  a  continuation  of  it, 
and,  like  the  nipple,  depends  for  its  color  upon  the  rete  mucosum. 
In  girls,  before  puberty,  it  is  simply  a  colored  circle  around  the 


DISEASES     OF     THE     BREAST.  487 

nipple,  but  after  puberty,  during  gestation,  and  in  lactating 
women,  it  becomes  more  or  less,  uneven,  in  consequence  of  the 
development  of  small  tubercles,  winch  open  on  the  surface,  con- 
tain a  mucous  excretion,  but  have  no  connection  with  the  lactiferous 
tubes  ;  in  fact,  they  are  not  very  different  from  the  common  seba- 
ceous glands  of  the  skin.  The  color  of  the  nipple  and  areola 
depend  very  much  upon  the  condition  of  the  uterine  apparatus, 
and  this  is  so  true  that  its  physical  aspect  has  long  been  held  as 
quite  expressive  of  the  condition  of  the  uterus.  Owing  to  the 
presence  of  erectile  tissue,  and  the  abundant  supply  of  blood- 
vessels, the  nipple  may  be  erected  as  in  the  case  of  the  male 
penis,  and  this  erection  may  depend  either  upon  a  state  of  the 
genitals,  or  upon  the  passions.  It  is  a  known  fact  that  there  is  a 
most  intimate  relation  of  sympathy  between  the  nipple  and  the 
uterus  or  the  genitals,  and  that  when  the  latter  are  in  a  state  of 
excitement,  the  nipple  is  more  or  less  erected,  and  that  there  is 
an  increased  engorgement  of  blood  in  the  nipple  at  such  times, 
and  hence,  too,  the  color  of  the  areola  is  then  deeper.  On  the 
other  hand,  to  illustrate  the  completeness  of  this  sympathy,  it 
may  not  be  amiss  to  state  that  many  females  are  so  sensitive  on 
the  nipples,  as  to  be  at  once  excited  by  passion  when  the  nipple  is 
touched  or  handled.  Instinctively  men  recognize  this  law  of 
inter-relation.  It  will  be  understood  that  the  rete  mucosum  is 
but  the  coloring  pigment  which  tinges  the  entire  skin,  and  that  it 
is  the  same  in  every  respect  as  that  deposited  in  the  eye  to  confer 
color.  The  more  abundantly  blood  be  supplied,  the  more  plenti- 
ful will  be  the  pigment,  and  the  darker  the  part  so  colored. 

1050.  The  mammary  gland  is  wrell  supplied  with  blood-vessels, 
the  chief  arteries  being  the  branches  of  the  thoracica  longa,  exter- 
nal mammary,  which,  like  the  former,  is  a  branch  of  the  axillary 
artery,  branches  of  the  internal   mammary  artery,  and   another 
branch  from  the  same.     Outside  of  these  principal  branches,  there 
are  a  number  of  less  important  branches  ramifying  through  them, 
most  of  them  reaching  the  nipple.     The  veins  begin  at  the  nipple 
in  minute  capillaries,  and  as  they  recede  from  it,  unite  in  large 
trunks,  entering  the  internal  mammary  and  intercostal  veins. 

1051.  The  absorbents  are  very  numerous  and  well  distributed 


488  DISEASES   OF   WOMEN. 

These  have  for  their  office  the  separation  of  the  milk  from  the 
blood.  The  nerves  of  the  mammary  gland  are  the  axillary  and 
the  sternal,  or  the  posterior  and  anterior  branches  of  the  above 
nerves,  so  called  from  their  distribution.  The  posterior  consists 
of  the  third,  fourth  and  fifth  branches  of  the  dorsal  nerves,  all 
of  which  reach  the  nipple.  The  anterior  consists  of  the  reflected 
branches  of  the  fourth  dorsal  nerve.  To  these  nerves  the  nipple 
is  indebted  for  its  extreme  sensibility.  There  are  many  openings 
and  a  few  stray  fine  hairs  in  the  areola,  but  the  orifices  do  not 
connect,  as  before  stated,  with  the  lactiferous  tubes. 

1052.  The  gland  is  in  reality  inclosed  between  two  fascia,  or  a 
single  fascia  which  has  separated  to  accommodate  the  gland,  and 
which  may  be  traced  to  the  ligamentous  substance  covering  the 
sternum.  From  this  fascia  numerous  fibrous  processes  are  given 
off,  which  Sir  A.  Cooper  calls  ligamenta  suspensoria,  since  by 
them  the  breast  is  suspended  in  its  situation.  They  are  firmly 
attached  to  the  skin,  and  though  admitting  the  gland  to  change 
position  enough  to  resist  violence,  they  still  hold  it  firmly  within 
certain  bounds.  These  ligamenta  suspensoria  distribute  them- 
selves upon  the  posterior  surface  of  the  skin,  adding  greatly  to  its 
whiteness  and  solidity.  They  also  pass  out  from  the  gland,  enve- 
lope the  lactiferous  tubes,  and  by  connecting  with  the  interior 
cutis  of  the  nipple,  prevent  its  displacement  from  the  gland. 
Between  these  ligaments,  if  such  they  may  be  called,  we  find 
folds  of  fat,  which,  acting  as  cushions,  prevent  the  gland  from 
sustaining  injuries  from  blows,  etc.  Indeed,  these  ligamenta  sus- 
pensoria form  a  net-work,  keeping  all  the  parts  together,  and  at 
the  same  time,  increasing  the  secreting  surface  of  the  gland.  The 
deeper-seated  fascia  sends  its  fibers  in  both  directions — into  the 
aponeurosis  of  the  pectoralis  major,  and  into  the  body  of  the 
gland,  thus  securing  it  to  the  body. 

1058.  The  tubes  of  the  mammary  gland  are  both  numerous 
and  varied ;  e.  g.,  the  straight  tubes  of  the  nipple,  the  areolar  tubes 
or  reservoirs,  the  mammary  ducts,  differing  only  in  their  disposition 
or  size ;  as  a  general  remark,  they  enlarge  as  they  pass  from  the 
nipple  to  the  reservoirs.  Along  side  of  these  tubes,  we  find  the 
arteries,  equally  distributed,  and  conferring  on  the  tubes  great 


DISEASES     OF     THE     BREAST.  489 

vascularity.  The  veins  do  not  run  parallel  always,  and  are  less 
branched,  the  functions  of  the  parts  requiring  a  greater  influx 
than  reflux  current.  The  tubes  are  lined  with  a  folded  mucous 
membrane,  which  is  highly  vascular.  It  must  be  borne  in  mind, 
that  most  of  these  ducts  are  entirely  separate  and  distinct  from 
all  others,  a  fact  which  is  easily  determined  by  injection. 

1054.  The   gland    itself  is  a  conglomerate  structure  of   small 
glands,  the   interspaces,  when   not  occupied  with  tubes,  arteries, 
veins,  or  nerves,  being  filled  with  fat.     The  glandules  vary  in  size 
from  the  head  of  a  pin  to  that  of  a  buck-shot,  and  when  injected, 
.are  nearly  round. 

1055.  Of  the  milk-cells,  little  need  be  said,  since  their  charac- 
ter can  not  materially  further  the  investigations  of  the  pathologist. 
Into  these  milk-cells  the  milk  is  secreted  from  the  blood,  and  of 
course,  if  not  in  a  physiological  condition,  soon  present  us  with  a 
pathological  state.     The  milk  passes  from  these  cells  to  the  mam- 
mary tubes,  and  after  reaching   the  areola,  is   deposited  in   the 
reservoirs  ready  for  use. 

1056.  The  axillary  and  internal  mammary  arteries  furnish  the 
gland,   and   though  greatly  distributed,   it  is    only   necessary  to 
regard  the  above  larger  trunks,  as  the   sources  of  supply.     The 
veins  of  the  breast  empty  into  the  axillary,  the  cephalic,  the  inter- 
costal, the  internal  mammary,  the  external  jugular  and  subclavian. 
The  veins  of  these  glands  are  often  engorged  in  certain  diseased 
states,  and  some  of  the  best  surgeons  have  been  in  the  habit  of 
opening  them,  to  allow  the  accumulated  blood  to  escape.     There 
is  no  doubt  but  it   affords,  as   I  have  often  witnessed,  immediate 
relief,  and  I  greatly  prefer  the  operation  to  the  more  tedious  one 
of  using  leeches  to  accomplish  the  same  end.     The  same   thing 
can,   however,   be   accomplished  with    great   certainty,   by   other 
treatment,  as  I  shall  have  occasion  hereafter  to  show. 

1057.  I   shall  be   sufficiently   understood,  if  I   say,   that   the 
breasts  are  literally   permeated  by  absorbent  vessels,  or  ducts, 
which,  when  many  unite,  may  sometimes  make  a  tube  as  large  as 
a  small  quill.     Such  a  one  is  found  on  the  inner  side  of  the  axil- 
lary vein,  and  between  the  first  rib  and   clavicle.     These  tubes 
are  intimately  connected  with  the   blood-vessels,  and  with   the 


490  DISEASES     OF     WOMEN. 

glandules,  etc.  These  absorbents  are  frequently  diseased,  and 
indeed,  many  of  the  more  malignant  forms  of  mammary  disease 
may  be  traced  to  that  source. 

1058.  The  nerves  of  the  breast  are  derived  from  the  dorsal 
branch  of  the  spinal  column,  and  are  so  minute  in  their  ramifica- 
tions that  the  anatomist  can  hardly  promise  himself  success  in 
tracing  them.     I  need  not  attempt  to  trace  the  reflex  nerves,  for 
the  labor  would  not  be  satisfactory,  even  though  I  had  space  at 
command. 

1059.  It  is  an  interesting  study  to  trace  the  effects  of  gestation 
and  lactation  on  the  breasts,  and  though  the  profession  have  a 
sort  of  general  and  indefinite  knowledge  on  the  subject,  it  must 
be  admitted  that  too  few  entertain  correct  views   on  this  point. 
To  arrive  at  expertness  in  reading  the  phases  through  which  the 
breasts  pass,  requires  a  close  and  careful  study  of  the  organ  in  the 
living  subject,  which  modest  women,  before  marriage,  will  not  per- 
mit, and  on  others  the  circumstances  are  usually  adverse.     But 
before  we  attempt  to  explain  the  nature  of  the  changes  which  are 
wrought  on  the  breast  by  ge'station  and  lactation,  it  may  be  well 
to  inquire  how  any  such  sympathy  can  exist  between  the  uterus 
and  its  appendages,  and  the   breasts?     It  is  presumed  that  no 
intelligent  physician  will   deny  that  such   sympathy  exists,  and 
hence  I  shall  not  here  refer  to  the  evidences  upon  which  the  asser- 
tion is  based.     Any  treatise  which  is  perfect  should  examine  the 
uterine  and  mammary  systems  as  constituting  the  same  apparatus, 
but  as  this  has  not  been  done,  I  can  only  briefly  show  why  this 
should  be  so. 

1060.  The  sympathy  between  the  uterine  appendages  and  the 
mammary  glands,  has  been  explained  by  supposing  that  the  epi- 
gastric artery  sent  more  blood  to  the  internal  mammary  artery, 
and  hence  to  the  breast  itself,  during  gestation  than  at  any  other 
times;   and  while  I  admit  that  this  is  altogether  probable,  the 
manifestation  between  the  genitals  and  the  breasts,  or  the  marn- 
inary  glands  and  the  uterine  appendages,  is  so  instantaneous,  as 
it  were,  that  I  think  we  must  look  to  more  rapid  transmission  of 
influences  than  such  as  can  be  conveyed  by  the  circulation.     This 
sympathy  is  entirely  nervous,   in  the  first  place,  and  whatever 


DISEASES     OF     THE     BREAST. 

influence  of  a  permanent  nature  is  transmitted  by  the  blood,  is  of 
a  secondary  character.  The  great  sympathetic  nerve,  whose 
branches  are  incorporated  with  the  dorsal  nerves  of  the  breast,  is 
also  largely  distributed  to  the  uterine  appendages.  It  is  to  be 
understood  that  other  parts  of  the  system  are  also  reached  by  the 
great  sympathetic,  and  other  parts,  also,  partake  of  the  sympathy, 
but  in  a  less  marked  degree.  I  have  already  stated  that  the 
nipple  is  furnished  with  erectile  tissue,  and  hence  we  might  expect 
it  to  be  more  prominently  effected  than  other  organs  in  which  no 
such  tissue  exists.  Very  many  facts,  illustrative  of  this  sympathy, 
might  be  cited,  but  one,  it  seems  to  me  is  quite  sufficient,  i.  e., 
advantage  is  taken  of  this  sympathy,  by  the  reckless  and  fear- 
less, to  produce  abortion  by  simple  irritation  of  the  nipple  at 
certain  periods  of  gestation.  And  whether  we  are  enabled  to 
give  a  satisfactory  explanation  of  the  phenomena  or  not,  the 
mere  fact  stands  undisputed,  and  we  must  base  our  conclusions 
on  it. 

1061.  During  gestation  more  blood  is  sent  to  the  breasts,  their 
color  is  darkened,  and  they  become  more  solid,  or  even  swell,  and 
become  quite  painful.     They  are  tender  to  the  touch,  and  if  it  be 
in  a  first  pregnancy,  they  at  once  undergo  that  evolution  by  which 
they  are  matured.     The  nipple  enlarges,  the  areola  becomes  much 
darker,  and  the  papillee  become  protuberent;   in  fact,  the  entire 
organ  looks  as  though  it  \vere,  as  it  is,  engorged.     The  increase 
of  the  diameter  of  the  areola   is   from   one   to   two  inches.     The 
increased  darkness  of  the  areola  depends  upon  the  more  abundant 
supply   of  the   rete  mucosum,  and  by  its  being  rendered  more 
visible  in  consequence  of  the  stretching  of  the  skin,  which  is  the 
necessary  result  of  the  enlargement  of  the   gland.     The  areola 
will  also  be  found  thickened,  in  consequence  of  the  development 
of  the  papillae.     The  glands  and  blood-vessels  around  the  nipple, 
and  on  the  body  of  the  gland,  will  also  be  more  prominent  than 
before. 

1062.  After  lactation  has  been  established,  all  these  indica- 
tions, except  deepening  of  the  color  of  the  nipple  and  areola,  are 
increased.     In  old  age,  the  tubes  of  which  I  have  been  speaking, 
become  more  or  less  ossified.    I  need  not  here  enter  into  a  descrip 


492  DISEASES     OF     AYOMEX. 

tion  of  those  influences  brought  to  bear  on  the  female  breast  about 
the  time  of  the  cessation  of  the  catamenia,  as  I  shall  have  occa- 
sion hereafter  to  treat  this  subject  more  in  detail.  I  have  given 
such  facts  as  I  conceive  to  be  necessary  in  the  proper  study  of 
the  diseases  of  the  breast,  and  to  which  too  little  attention  has 
been  paid  by  surgeons.  Perhaps  no  surgeon  in  America,  of  rny 
age,  has  had  more  experience  in  treating  the  diseases  of  the  female 
breast  than  myself,  and  certainly  none  have  been  more  successful ; 
which  success  I  imagine  to  depend  both  upon  my  knowledge  of 
the  glands  and  the  plans  which  I  have  adopted  for  the  treatment 
of  their  diseases.  From  these  considerations,  I  feel  warranted  in 
laying  my  experience  before  the  profession,  fully  believing  that 
when  others  are  guided  by  the  same  principles  that  I  have 
adopted,  they  will  be  equally  successful. 

1063.  Numerous    morbid    specimens    ought    to    be    carefully 
examined,  for  I  assure  you  that  an  intimate  acquaintance  with 
their  appearance,   structure,  and  physical  characteristics,  will  be 
highly   advantageous   to  you,   both   in   determining  the  kind  of 
diseased  growth,  and  its  mode  of  development.     Were  this  not  so, 
experience   could  never  add  to  the  success  of  a  surgeon  ;  your 
knowledge  of  the  general  pathology  of  such  growths  would  be  all 
that  would  be  requisite  to  enable  you  to  treat  them  with  entire 
success — a  supposition  which  is  not  to  be  entertained.     By  .com- 
paring together  a  great  number  of  such  morbid  structures,  we 
learn  to  recognize  the  peculiarities  of  each,  and  to  detect  those 
peculiarities  in  practice.     If  there  is  any  science  in  surgery  and 
medicine,  of  course  it  will  be  applied  only  when  we  understand 
the  pathological  states  that  are  to  be  reduced  to  physiological 
conditions.     There  are  certain  forms  of  morbid  structure,  for  the 
removal  of  which  there  are  specific  agents,  and  nothing  but  care- 
ful examinations  of  those  structures  can  enable  you  to  diagnose 
them. 

1064.  If  you  shall  have  first  examined  these  structures,  and 
made    yourselves    perfectly   familiar    with    their    pathology,    the 
strong    presumption    is    that   you   will   not   commit    those    grave 
blunders  which  have  so  disgraced   many  honorable  members  of 
the  profession.     The  necessity  for  thoroughly  studying  the  chai- 


DISEASES    OF    THE    BREAST.  498 

acter  of  these  growths,  in  all  possible  ways,  will  be  sufficiently 
obvious  by  remembering  that  diseases  of  the  breast  may  be 
properly  divided  into  two  great  classes,  the  curable  and  the 
incurable.  The  physician,  who  is  entitled  to  be  called  scientific, 
never  guesses  at  what  he  is  to  do  ;  if  he  does,  he  is  a  quack  who 
strikes  in  the  dark,  and  who  is  as  apt  to  kill  as  to  cure.  I  have 
so  frequently  seen  operations  on  the  breast,  which  I  now  know 
were  unnecessary,  that  I  feel  it  my  duty  to  guard  you  against 
rashness  in  this  respect. 

1065.  The    diseases    of    the    female    breasts    are    exceedingly 
numerous,    and    are    greatly   modified   in  different    constitutions. 
What  would  be  a  dangerous  tumor  in  one  case,  and  which  would 
require  a  prompt   operation,    would    be   simple   in   another,   and 
require  no  operation.     I  need  hardly  call  your  attention  to  age 
and  the  general   health,    to   impress   this    truth,    and    yet    some 
surgeons,  judging  from  the  language  of  the  books,  and  from  what 
I  have  seen,  act  upon  the  principle  that  a  tumor  is  a  tumor,  and 
must,  in  all  cases,  be  removed.     I  venture  to  affirm,  that  one-half 
of  the  tumors  of  the  breast  which  are  called  cancer,  are  not  truly 
such,  and  in  this  opinion  I  do  not  stand  alone. 

1066.  The  causes  which  give  rise  to  these  tumors  are  also  so 
exceedingly  varied,    that  the   fair    presumption  is   a  variety   of 
effects ;  opposite  causes  usually  producing  opposite  effects.     Sir 
Astley  Cooper  has   drawn   a  delightful  picture   in  his   excellent 
work  on  the  breasts,  after  having  endeavored  to  impress  upon  the 
profession  the  great  necessity  of  carefully  manipulating  the  living 
tumor,  and  of  scrutinously  examining  the  morbid  specimens  on 
exhibition.     He  says : 

1067.  "  The  result  of  such  knowledge  is  frequently  the  source 
of    great   security   and   happiness    to   a  person   afflicted  with   a 
disease  in  the  breast,  as  well  as  of  great  satisfaction  to  the  sur- 
geon.    I  have  scarcely  witnessed  a  stronger  expression  of  delight 
than  that  which  has  illumined  the  features  of  a  female  —  perhaps 
the  mother  of  a  large  family  dependent  upon  her  for  protection, 
education,  and  support  —  who,  upon  consulting  the  surgeon  for 
some  tumor  in  her  bosom,  and  expecting  to  hear  from  him  a  con- 
firmation   of    the    sentence    she    had    pronounced    upon    he]  self. 


494  DISEASES      OF     WOMLX. 

receives,  on  the  contrary,  an  assurance  that  her  apprehensions  are 
unfounded.  Pale  and  trembling  she  enters  the  surgeon's  apart- 
ment, and,  baring  her  bosom,  faintly  articulates  —  Sir,  I  am  come 
to  consult  you  for  a  cancer  in  my  breast ;  —  and  when,  after  a 
careful  examination,  the  surgeon  states,  he  has  the  pleasure  of 
assuring  her  that  the  disease  is  not  cancerous — that  it  has  not  the 
character  of  malignancy — that  it  is  not  dangerous,  and  will  not 
require  an  operation  ;  the  sudden  transition  from  apprehension  to 
joy  brightens  her  countenance  with  the  smile  of  gratitude  ;  and 
the  happiness  of  the  moment  can  hardly  be  exceeded,  when  she 
returns,  with  delighted  affection,  to  the  family  from  which  she  had 
previously  considered  herself  destined  soon  to  be  separated  by 
death,  with  the  alternative  only  of  being  saved  by  a  dubious  and 
painful  operation." 

1068.  For  the  purpose  I  have  in  view,  I  shall  adopt  the  very 
natural  classification  of  affections  of  the  breasts,  which  is  made  by 
Birkett,  viz. : 

1.  Diseases  occurring  before  puberty; 

2.  Diseases  occurring  during  the  establishment  of  puberty;  and 

3.  Diseases  occurring  after  the  establishment  of  puberty. 

1069.  It  will  be  apparent  that  the  diseases  occurring  in  either 
of  these  periods  will  admit  of  a  very  wide  and  diversified  subdi- 
vision, each  of  which  will  be  examined  in  detail,  as  I  progress  with 
the  general  subject.     It  is  difficult  to  determine  at  what  precise 
age  the   earliest    development   of  mammary  disease    occurs,  but 
within  a  few  days  of  birth.     The  mammary  gland,  or  the   rudi- 
mentary gland,  begins   to  develop  after  the  sixth  month  of  foetal 
life,  and,  like  any  other  gland,  may  at  once  become  the  subject 
of  disease.     Diseases    occurring   in  the    mammary  glands  before 
puberty,  and  especially  when  the  patient  is  still  an  infant  or  child, 
are  mostly  of  an  inflammatory  character,  and  they  vary  only  in 
the  extent  and  termination  of  that  inflammation. 

1070.  Within   two   or  three  days  after  birth,  the  mammae,  or 
their  rudiments,  acquire  a  state  of  tumefaction,  and  soon  there  is 
observed,  issuing  from  the  papillae,  a  milk-like  secretion,  which  of 
itself,  and  independent  of  all  other  circumstances,  is  a  demonstra- 
tive  proof   of  the    preexistence   of  the    secreting  gland.     Many 


DISEASES     OF     THE     BREAST.  495 

mothers,  exceedingly  ignorant  of  the  processes  of  nature,  and 
over-careful,  become  very  anxious  to  have  this  secretion  removed, 
or  to  have  the  excretion  stopped.  To  accomplish  its  stoppage, 
they  resort  to  frictions,  etc.,  and  inflammation  results  as  the 
consequence  of  such  harsh  treatment  of  the  tender  gland.  The 
attention  of  the  parent  \s  first  called  to  the  part  by  the  hardness, 
tumefaction,  and  tenderness  which  the  child  evinces  when  it  is 
touched.  Now  all  this  is  natural  enough,  and,  if  let  alone  for  a 
few  days,  will  cease  of  itself,  and  leave  the  parts  in  a  healthy 
condition.  It  is  true  that  in  rare  cases,  the  tumefaction  may  last 
for  some  days  ;  the  natural  inflammation  may  assume  a  somewhat 
intense  degree ;  but  still,  if  it  be  let  alone,  it  will  resume  its 
natural  state  in  a  short  time. 

1071.  Nothing   can   be   more   irrational  than  to  rub,  squeeze, 
pinch  or  irritate  so  tender  an  apparatus  as  the  developing  mam- 
mary gland.     Where  this  injudicious  course  is  adopted,  there  may 
be  extensive  and  acute  inflammation,  ending  in  abscess,  in   which 
event    the    assistance    of    the    physician    will    be    needed.       The 
treatment  must,  in  every  case,  be  on  general  principles,  modified 
by  the  tender  age  and  constitution  of  the  patient.     The  inflam- 
mation often  extends  beyond  the  glandular  structure,  as  was  the 
case  with  a  child  less  than  one  month  old,  seen  by  Mr.  Wagstaffe, 
in  which  the  inflammation  extended  from  the  upper  part  of  the 
breast  down  the  right  side  to  the  umbilicus.     Where  the  attack  is 
so  severe  as  in  this   case,  the  inflammation  spreads  very  rapidly 
over  a  large  space.     To  bathe  the  inflamed   surface  with  cooling 
lotions,  and  to  poultice  the  abscess  which  may  form,  is  about  all 
the  treatment  that  is  required. 

1072.  Again,  the  tumefaction  and  pain  may  follow  the  cessation 
of  hemorrhage  from  the  vulva,  as  was  observed  by  Barrier  in  a 
female  infant  only  five  days  old.     In  this  case  there  was  but  little 
attending  inflammation,  yet  the  case  was  interesting  as  another 
evidence  of  the  very  close  sympathy  existing  between  the  mammae 
and  the  genitals. 

1073.  Birkett  reports  a   case  in  which  there  was   an   abscess 
formed  in  the  breast  of  a  child   three   months   old,   and   whose 
mother  stated  to  Mr.  Birkett  that,  unlike  her  other  children,  the 


496  DISEASES     OF     WOMEN. 

breasts  of  this  one  had  not  had  the  usual  milky  discharge  from 
the  mammary  gland ;  and  in  another  case,  'where  the  child  was 
sixteen  months  old,  an  abscess  was  present,  and  the  breast  swelled 
very  much,  in  which  there  was  also  a  discharge  from  the  vulva, 
showing  that  the  genitals  were  in  an  irritated  condition — another 
evidence  of  the  sympathy  of  the  parts.  But  however  often  we 
may  be  called  to  treat  such  tumefactions  and  swelling  of  the 
infantile  breasts,  we  shall  find  the  symptoms  rapidly  subsiding 
after  the  slightest  attention ;  and  that  in  no  case  do  they  end  in 
serious  lesions. 

1074.  When  we  approach  nearer  to  puberty,  the  breasts  become 
more  subject  to  disease,  and  not  unfrequently  we  shall  find,  that 
they  then  readily  assume  a  form  of  malignancy  which  demands 
our  utmost  attention.     And  what  adds  to  the  difficulties  attendant 
on  their  treatment,  is  the  modesty  of  those  thus  afflicted,  and  their 
indisposition  to  permit  examinations  to  be  made,  while  the  disease 
is  yet  in  its  incipient  stages. 

1075.  With  the  complete  development  of  the  ovaries,  and  the 
establishment    of    the    catamenia,   the    mammary  glands    rapidly 
enlarge,  and  assume  their  perfect  shape ;  the  areola  deepens,  and 
the   nipple   evolves  into    its    natural    prominence,  of   course  not 
acquiring  the   size   and   shape   which  it  is   afterward    to    attain. 
Changes   thus  occurring  are  perfectly  natural,  and  do   not  com- 
monly give  rise  to  disturbances  which  require  surgical  attention ; 
yet  they  sometimes  do,  and  it  is  therefore  incumbent  on  me  to 
make  some  suggestions  respecting  those  diseased  conditions. 

1076.  We  are  to  bear  in  mind  that  this  natural  period  of  female 
development  varies  with  climate,  habits  and  constitution.     It  may 
be  stated  to  range  from  nine  to  sixteen  years  of  age,  and  M. 
Bourgat  Saint  Hilaire  relates  the  case   of  a  little  girl,  born  in 
Louisiana,  on  the  13th  of  December,  1837,  having  from  birth  well- 
formed  breasts,  and  having  the  pubes  covered  with  hair,  as  in  a 
girl  of  fifteen.     The  catamenia  appeared  when  the  child  was  three 
years   of  age,  and   continued   to    appear  monthly,  as  in  women 
generally,  after  puberty  has  been  fully  established.     The  quantity 
of   the    catamenial   discharge  was   as   great    as    in   women   fully 
developed ;  the  time  of  the  discharge  being  usually  four  days 


DISEASES     OF     THE     BREAST. 
This  is  certain!  v  an  anomalous  case,  but  none  tbe  less  interesting 

"  O 

as  a  fact.  A  similar  case  is  reported  in  vol.  2,  of  the  Medico- 
Chirurgical  Transactions,  by  Sir  Astley  Cooper.  This  child  was 
the  daughter  of  a  waterman  at  Lincoln.  The  catamenia  appeared 
before  she  was  three  years  old;  at  first  occurring  at  long  intervals, 
but  becoming  more  regular  as  she  acquired  age.  "  The  catame- 
nia," says  Sir  Astley,  "exactly  resembled  that  of  most  women, 
except  that  it  was  rather  of  a  darker  color."  The  breasts  were 
very  full,  being  as  large  as  those  of  most  women  at  twenty  years 
of  age.  Her  pelvis  was  well  developed,  and  the  pubes  covered 
with  a  light-colored  hair.  She  did  not  seem  to  possess  the  sexual 
desire,  and  was  not  more  modest  than  most  children  at  her  age. 
When  six  years  of  age  she  menstruated  regularly  every  21st  day, 
the  discharge  lasting  four  days.  She  had  frequent  leucorrhea, 
and  when  in  her  seventh  year,  exhibited  much  more  modesty  than 
before.  This  girl  had  other  sisters  who  did  not  manifest  any 
forwardness.  Other  cases  have  been  recorded,  but  these  are  quite 
sufficient  to  show  that  the  breasts,  in  connection  with  the  ovaries, 
may  be  developed  at  a  very  early  age  ;  while  on  the  other  hand, 
numerous  cases  are  recorded  where  neither  the  ovaries  nor  the 
breasts  were  ever  developed. 

1077.  Even  at  the  early  age  of  twelve,  or  at  the  period  when 
puberty  is  being  established,  the  breasts   may  become  the  seat  of 
cancer,  and  other  malignant  diseases,  though  such  instances  are 
not  common,   by  any  means.      Mr.  Bransby   Cooper  relates   the 
case  of  a  girl  aged  13,  on  whom  he  found  carcinoma  medullse  of 
the  breasts,  Avhich  was  removed,  and  who   died,  notwithstanding 
the    operation.      Lyford    reports   a   similar   case    in    the    London 
Lancet,    and   also   refers    to   a  specimen    in  the   museum   of  St. 
Bartholomew's  Hospital,  which  was  taken  from  a  girl  aged  sixteen 
years. 

1078.  The  diseases  most  apt  to  attack  the  mammary  gland,  at 
the  period  of  puberty,  are  inflammation  and  its  sequelae,  and  often 
ending  in  chronic  abscess,  which,  if  suffered  to  run  on,  may  finally 
develop  itself  into  malignant  tumor.     Girls,  at  the  establishment 
of  puberty,  have   most  to   fear  from   tubercular  diseases   of   the 
lungs,  mournful  instances  of  which  we  see  almost  daily. 

32 


498  DISEASES     OF     WOMEN. 

1079.  The  surgeon  who   expects  to  master  the  treatment  of 
diseases  incident  to   the  breasts,  must  not  neglect  to  glean  from 
every  source  all  such  information  as  will  lead  into  an  understand- 
ing  of  the  basis   of  those  pathological   states  which  form  their 
development.     He  ought  to  examine  with  a  microscope  the  corn- 
posit  cells  of  every  morbid  growth,  the  pus,  the  fibres,  the  blood- 
vessels, the  tissues,  and  the   chemical  nature  of  the  attendant 
secretions. 

1080.  As  it  will  be  to  the  diseases  which  affect  the  mammary 
glands  after  puberty,  that  I  shall  direct  your  attention  more  par- 
ticularly, I  close  this  lecture  by  reminding  you  of  some  of  the 
effects  of  common  inflammation   in  the  breasts.     This  has  been 
divided,  by  Sir  Astley  Cooper,  into  three  stages,  which  he  very 
appropriately  terms    adhesive,  suppurative,  and  ulcerative.     Ad- 
hesive inflammation  produces  a  firm   and  very  sensitive  enlarge- 
ment, which,  in  consequence  of  the  tardiness  of  the  dense  fascial 
membrane  in  yielding  to  the  enlargement,  often  occasions  excru- 
tiating  pain   and  suffering  to   the   patient.       The  solidity  of  the 
swelled  gland  depends  upon  the  engorgement  of  the  interstices 
with  the  serous  and  fibrous  portions  of  the  blood.      The  blush  of 
inflammation  is  well   marked,  and   the  throbbing   quite  sensible. 
Shiverings  reveal  the  fact  that  the  general  system  is  influenced 
by  the  local  inflammation.     This  shivering  is  succeeded  by  heat 
and  copious  perspiration.     As  the  disease  progresses  the  cuticle 
separates,  ulceration  is  established  in  the  cutis,  and  a  discharge 
follows.     This  process  is  completed  in  from  one  to  three  weeks — 
the  disease  running  its  course  much  more  rapidly  in  some  than  in 
others.     This  kind  of  inflammation  mostly  attacks  young  mothers, 
and  for  obvious  reasons.     When  we  endeavor  to  arrest  the  first 
stage,  we  shall  not  often  be  compelled  to  treat  the  suppurative 
stage.      Fomentations,   and  washings  with   cool  lotions,  will  be 
found  of  great  benefit,  and  a  poultice,  in  which  there  has  been 
incorporated  a  large  quantity  of  Veratrin,  will  be  serviceable.    Or, 
if  the  suppurative  stage  has  been  reached,  then  we  must  rely  upon 
hop    and   poppy  fomentations,  and  hyoscyatnus  poultices.      The 
abscesses  of  the  ulcerative  stage  are  to  be  opened  with  the  lancet, 
as  soon  as  there  is  much  evidence  of  accumulated  matter,  and 


DISEASES     OF     THE     BREAST.  499 

then   the   part  is  to  be  treated  with  poultices  and  fomentations — 
the     minutia  of  which  will  be  noticed  hereafter. 

1081.  The  limited  space  at  my  command,  compels  me  to  abbre- 
viate what  I  have  to  say  in  relation  to  the  diseases  of  the  breasts, 
to  say  nothing  of  those  minor  affections  which  frequently  require 
medical  or  surgical  interference.     The  acute  inflammations  which 
are    to   be  observed  occasionally  attacking  the  breasts,  does  not 
differ  very  materially  from  the  same  forms  of  inflammation  when 
observed  elsewhere,  and  if  there  be  a  difference,  it  is  easily  under- 
stood   to    result  from    the   peculiar   anatomical    structure   of   the 
mammary  gland.    It  is  to  be  remarked,  however,  that  the  intimate 
relations    which  exist  between   the  breasts   and   the   uterus,  and 
between  the  uterus   and  the  great  nervous  centers,  may  occasion 
by  reflex  or  secondary  actions,  peculiar  hysterial  or  nervous  phe- 
nomena,  which    do  not   attend    the   acute   inflammation   of  other 
localities.      The  acute  sufferings  attendant  on  inflammation  of  this 
gland   arise  from  its  peculiar  sensitiveness  ;  its  perfect   nervous 
connections,  and  in  the  treatment  of  common  acute  inflammation 
of  the  gland,  we  shall  be  compelled  to  induce  an  obtuseness  of 
the   nervous   centers,    as    far   as    possible,   to   blunt  the    sensory 
ganglia. 

1082.  From  peculiarity  of  structure,  there  is  a  great  tendency  to 
the  confinement  of  the  inflammation  to  a  particular  spot,  where  we 
soon  observe  that  the  inflammation  has  passed  through  its  adhesive 
.stage,  and  has  become  hard,  shining,  and  marked  by  a  throbbing 
sensation,  which  may  be  regarded  as  more  or  less  characteristic 
of    the  suppurative   process.     The    general   system    has    already 
partaken  of  the   disturbance,   and  we  witness  the   occurrence  of 
tremors,  shiverings,  heat,  and  dryness  of  the   cuticular  surface, 
and,  finally,  profuse  perspiration.     Soon  after,  the  cuticle  sepa- 
rates,   or    splits  into    rugous    cracks,  and    ulceration  is  at    once 
established,  the  matter  being  discharged  through    the    apertures 
or  cracks  in  the  cuticle. 

1083.  In  any  particular  case,  unless  by  remedies  we  may  arrest 
the  progress  of  the  disease,  all  these  stages  will  have  been  accom- 
plished  in  from    two   to   three  weeks.      Individual    peculiarities, 
arising  from  general  irritability,  the  depth  to  which  the  abscess  has 


500  DISEASES     OF     WOMEN. 

formed,  etc.,  will  lengthen  or  shorten  each  case,  but  usually  all 
the  stages  are  completed  in  the  course  of  three  weeks,  and  after 
this,  the  whole  tendency  of  the  disease  is  to  malignancy.  Inflam- 
mation of  this  kind  results  from  various  causes,  some  of  the  most 
palpable  of  which  I  shall  notice.  When  the  child  is  first  put  to 
the  breasts,  its  suction-efforts  tend  to  draw  an  extraordinary  flow 
of  blood  in  the  direction  of  the  nipple.  This  is  the  case  only 
while  the  child  draws  before  the  milk  begins  to  flow.  All  parts 
of  the  tissue  thus  become  periodically  injected  by  an  unusual 
quantity  of  blood,  which,  not  returning  with  equal  facility,  is  left 
in  the  engorged  tissues,  where  it  becomes  a  source  of  irritation, 
and  finally,  consequently,  of  inflammation.  Then,  again,  there  is 
constant  and  violent  exposure  of  the  breasts  to  a  cold  air,  after 
they  had  been  snugly  and  warmly  accommodated  in  the  dress. 
At  one  moment,  they  are  full,  warm,  and  dry,  and  a  few  moments 
afterward,  they  are  flaccid,  cold  and  wet,  favoring  great  irregu- 
larities in  the  circulation,  and  thus  maintaining  a  ready  impressi- 
bility to  every  source  of  irritation.  The  disastrous  practice  of 
nurses  and  midwives  encouraging  the  use  of  stimulating  drinks, 
and  refusing  the  child  the  use  of  the  breasts,  before  several  days 
have  elapsed,  and  when  the  callostrum  corpuscles  have  become 
agglutinated,  has  given  rise  to  many  a  mammary  abscess,  and  no 
doubt  the  same  practice  has  been  to  some  extent  encouraged  by 
physicians. 

1084.  In  treating  the  adhesive  stage  of  this  kind  of  inflamma- 
tion, we  should  endeavor  to  equalize  the  general  circulation,  to 
move  the  bowels,  stimulate  the  functions  of  the  skin,  by  the  free  use 
of  diaphoretics,  and  to  brace  the  system  by  the  free  and  judicious 
use  of  tonics,  not  forgetting  the  great  value  of  warm  fomentations 
to  the  breasts.  The  use  of  cathartics  will  often  prove  of  great 
advantage  by  their  revulsive  efforts.  If  these  means  do  not  arrest 
the  disease,  and  the  second,  or  suppurative  stage  shall  have  been 
reached,  then  poultices  of  Poppy  and  Gelseminum  should  be 
applied,  the  breast  being  bathed  in  a  decoction  of  Veratrum 
Viride,  all  of  which  should  be  tepid.  The  internal  administration 
of  the  following  pill,  at  the  same  time,  will  be  found  to  be  of  great 
value : 


DISEASES     OF     THE     BREAST.  501 

5*    Gelsemin,  gr.  iii. 
Podophyllin,  gr.  ii. 
Sanguinarin,  gr.  i. 
Scutellarin,  gr.  iv. 

Make  into  six  pills,  and  give  one  at  morning,  one  at  noon,  and 
one  at  bed-time.  If  the  bowels  are  already  open,  then  omit  the 
Podophyllin,  and  substitute  in  its  place  Quinine,  iv.  gr. 

1085.  In  regard  to  the  abscess  which  may  have  formed,  let  me 
here  remark,  that  they  ought  to  be  opened  in  every  instance,  no 
matter  whether  they  shall  be  deep  or  shallow.     No  possible  harm 
can  result  to  impede  the  cure,  but,  on  the  other  hand,  the  use  of 
an  abscess-lancet  will  greatly  relieve  the  immediate  sufferings  of 
the    patient,  and    enable    us    to   inject   a   very   weak  solution  of 
Sesqui-Carbonate  of  Potash,  or  of  Muriated  Tincture  of  Iron  into 
the  abscess,  which  will  very  greatly  facilitate  adhesion,  granula- 
tion, and   restoration   of   the   organ.      Of   course   every   opening 
should    be   made  where    the    fluctuation    is    most    distinct.      The 
neglect  of  these  abscesses  and  endeavors  to  discuss  them  when 
once  formed,  is  a  prolific  source  of  malignant  mammary  tumors. 
Sir  Astley  Cooper,  in  his  excellent  treatise  on  this  subject,  relates 
a  case  where  an  ordinary  milk-abscess,  which  had  been  somewhat 
neglected,   degenerated    into  a  true  fungoid   excrescence   of  the 
whole  gland,  which  finally  destroyed  the  woman's  life.     After  the 
abscess  has  been  healed,  if  a  peculiar  hardness  remain,  as  is  often 
the  case,  then  it  should  be  an  object  to  discuss  such  induration  by 
the  use  of  Iodine,  etc. 

1086.  The  child   should  not  be  allowed  to  suck  the  diseased 
breast,  but  the  milk  should  be  regularly  drawn  by  a  glass  tube 
prepared  for  the  purpose ;  or  else  by  the  use  of  the  breast-pump. 
The  breast  ought  not  to  be  squeezed  or  roughly  used,  as  every 
physician  of  much  experience  has  seen  a  greater  or  less  number 
of    mammary    ulcers    which    have    arisen    from    such    improper 
manipulation  of  the  breasts.     Abscesses  of  the  mammary  glands 
often  arise  from  cracks  and  fissures  on  the  nipple,  rendering  it 
unpleasant  to  have  the  child  put  to  the  breasts,  and  hence  they 
are  allowed  to  become  engorged  with  milk,  which  soon  produces 


502  DISEASES     OF     WOMEN. 

irritation  and  inflammation.  This  is  particularly  apt  to  be  the 
case  when  one  breast  is  sore,  and  both  the  mother  and  physician 
should  be  guarded  against  allowing  the  milk  to  accumulate  in  the 
breast  over  and  above  the  ordinary  quantity,  since  the  incidental 
distention  would  greatly  favor,  or  give  rise  to  inflammation — 
which,  in  every  instance,  is  to  be  regarded  as  a  symptom  of  a 
pathological  state,  requiring  close  and  circumspect  attention. 

1087.  Incidental  to  chronic  inflammation,  there  is  another  ab- 
scess which  requires  the  most  careful  inspection,  and  as  it  is  long 
in  forming,  it  has  been  denominated  the  chronic  abscess.  It  is 
distinguished  from  acute  abscess,  by  the  length  of  time  in  which 
it  is  forming,  by  the  little  pain  accompanying  it,  absence  of  heat 
and  redness  on  the  breast,  and  the  want  of  rigors  and  those  other 
constitutional  disturbances  Avhich  have  been  mentioned  as  being 
characteristic  in  acute  abscess.  For  these  reasons  we  are  not  led 
to  suspect  the  formation  of  matter,  and  thus  a  malignant  tumor  is 
suffered  to  arise  and  progress  with  its  ravages,  which,  had  the 
nature  of  the  disease  been  clear  from  the  first,  would  have  been 
averted.  Upon  pressure  over  such  abscesses,  the  patient  is  very 
sensitive,  and  if  we  examine  closely,  the  presence  of  matter  will  be 
detected  by  fluctuation.  Let  it  be  borne  in  mind  that  there  is 
always  more  or  less  induration  around  the  matter  so  formed,  and 
hence  we  are  liable  to  suppose  that  there  is  a  tumor  requiring 
excision.  Sir  Astley  Cooper  reports  several  cases  which  had 
been  sent  to  him  of  this  nature,  and  which  had  deceived  those 
who  sent  them.  In  lancing  such  abscesses,  or  any  others,  the 
lancet  should  be  put  in  so  as  not  to  cut  the  lactiferous  tubes 
across — in  other  words,  the  blade  should  be  put  in  parallel  to  the 
nipple,  as  the  tubes  run  from  the  base  towards  the  apex  of  the 
gland.  It  has  been  customary  to  give  mercurials  in  this  abscess, 
to  alter  the  secretions ;  but  it  seems  to  me  that  no  practice  could 
be  more  injudicious.  That  Stillingia,  combined  with  some  of  the 
more  positive  tonics  are  indicated,  I  do  not  deny ;  but  generally, 
a  due  attention  to  the  functions  of  the  kidneys,  skin,  liver, 
stomach,  and  the  diet  are  all-sufficient,  along  with  opening  the 
abscess,  to  effect  a  cure.  If,  after  the  abscess  has  been  opened, 
sinuses  form  that  refuse  to  heal,  then  stimulating  injections  are 


DISK  A  S  E  S     0  F     T  1 1  E     B  R  EAST.  503 

indicated,  in  order  to  produce  that   inflammation  which  the  tissues 
were  unable  to  set  up. 

1088.  There  is  another  abscess  of  the  breasts  which  seems  to  me 
to  warrant  some  attention.    I  refer  to  what  Sir  Astley  Cooper  calls 
the  Lactiferous   Swelling,  which  is  nothing  more  nor  less  than  a 
lactiferous  aneurism — the  excessive  enlargement  of  a  single  milk 
tube.     To  enable  the  practitioner  to  recogni/e  it  at  once,  I  beg  to 
briefly  describe  it.      The  swelling  is  like  a  ridge  running  from  the 
nipple  toward  the  base  of  the  gland.     The  woman  complains  of  a 
feeling  of  great  distention,  Avhich  is  almost  insupportable,  wThen 
the  child  attempts  to  suck,  owing  to  the  increased  flow  of  milk  in 
the  adjoining  tubes.     The  breast  is  uncolored,  but  the  cutaneous 
veins  are  greatly  distended,   while  the  fluctuation  in  the    tumor 
is  most  distinct. 

1089.  When  opened,  little  or  nothing  than  milk  is  discharged, 
and  if  the  opening  is  suffered  to  be  closed,  the  tube  is  again  soon 
similarly  distended.     If  not  opened   by    the    surgeon,    ulceration 
occurs,  and  an  opening  follows  near  the  nipple,  which  can  hardly 
be  healed  until  the  child  has  ceased  to  suck,  and  until  milk  is  no 
longer  secreted.     The  requisite  treatment  is  apparent — puncture 
the  tumor,  and  keep  the  child  from  the  breast  until  milk  is  no 
longer  secreted.     Or  if  the  child  be  yet  very  young,  and  it  be 
desirable  to  retain  the  activity  of  both  glands,  open  the  abscess, 
making  a  free  incision,  and  then  inject  a  stimulating  solution,  so 
as   to    induce   inflammation,   during   the   progress   of    which,   the 
breast  may  be  artificially  relieved  of  its  milk,  until  adhesion  has 
been   completed.     With  all  justice,  this  disease  might  be  called 
Mammary  Ranula,  which   it  resembles   in  every  respect,   except 
that  the  one  is  produced  by  an  accumulation  of  saliva,  and  the 
other  of  milk. 

1090.  There  are  four  kinds  of  watery  tumors  of  the  mammary 
glands.  The  first  of  these  are  mere  sacs  filled  with  serous  fluid, 
and  named  by  Sir  Astley  Cooper  Cellulose  Hydatids.    This  variety 
is  distinguished  by  freedom  from  pain,  enlargement  of  the  breast, 
no  fluctuation  at  first,  but  which  finally  appears  ;  the  breasts  then 
grow  more  rapidly,  and  fluctuation   can   soon  be  detected  in  a 
number  of  places  at  one  time;  the  cutaneous  veins  are  varicose 


504  DISEASES     OF     AYOMEX. 

and  the  breasts  though  many  pounds  heavier  than  usual — perhaps 
three  or  four  times  as  large  as  common — are  still  free  from  pain; 
but  a  few  patients  complain  of  heat,  and  sometimes  pain  in  the 
shoulder.  The  tumor  moves  easily  on  the  pectoral  surface,  and 
is  at  the  same  time  very  pendulous.  It  may  involve  a  part  or 
the  whole  of  the  mammary  gland. 

1091.  In  its  progress  at  one  of  the  points  of  fluctuation,  the 
breast  inflames,  ulcerates  and  opens,  when  a  glairy  mucilaginous 
fluid,  mixed  with  serum,  is   discharged.     Other  sacs,  if  there  be 
more  than  one,  go  through  the   same   process,   forming   sinuses, 
which    do    not  readily  heal.     The    general  health   may  be,  and 
mostly  is,  good;  nor  do  the  adjacent  structures  seem  to  partake 
of  the  disease.     The  disease  may  progress,  until  so  much  fibrous 
structure  has  been   formed,  that  the  breast  becomes  one   great 
tumor,  which  fills  the  patient  and  her  friends  with  the  apprehen- 
sion  of  cancer.     These    larger  sacs    contain    smaller    ones,    and 
these  again,  yet  smaller  ones,  giving  the  idea  of  cellular  dropsy. 
They  vary  in  size,  of  from  one-twentieth  to  half  an  inch  in  dia- 
meter, and  rarely  to  one  inch.     The  sacs  are  larger.     The  cysts 
are  exceedingly  vascular,  the  veins  are  engorged,  and  in  opera- 
tions bleed  profusely,  which  disposition  is  manifested  even  after 
the  tumor  has  been  extirpated.     There  is  no  danger  of  confound- 
ing it  with  either  of  the  abscesses  already  described,  and  when 
the  sac  is  opened,  the  surgeon  is  at  once  led  to  a  knowledge  of 
the    complaint.     Sometimes   a  true  scirrhous  tubercle    will  have 
hydatids   associated,  but  then  we  shall  find  that  there   are   also 
present  those  darting  pains,  excessive  hardness,  etc.,  characteristic 
of    scirrhus.       For   the    treatment    of    this    complaint,    there    is 
required  only  a  simple  dissection  of  the  sacs  and  the  immediately 
surrounding   indurations,   which  usually    effects   a   radical    cure, 
with  little  or  no  further  treatment,  than  a  genial  diet.     Though 
the  disease  is   not  generally  painful,  there   are    some  cases    in 
which  much  uneasiness  is  felt  from  the  first,  as  has  been  noticed 
by  Cooper  and  others.     These  cases,  however,  seem  to  be  excep- 
tions, and  may  generally  be  accounted  for  by  idiosyncrasy,  etc. 

1092.  The  second  form  of  hydatid  disease  is  marked  by  the 
following  peculiarities :  the  breast  is  enlarged ;  hardened  by  fibri- 


DISEASES     OF     THE     BEE  AST.  -505 

nous  effusion  ;  there  are  distributed  through  it  various  sacs  con- 
taining serum,  which  fluctuate  ;  from  the  inner  wall  of  the  sacs 
hang  a  number  of  polypous  bodies  which  seem  to  float  in  the 
fluid  contained  in  the  sacs  ;  many  of  these  bodies  are  detached  and 
floating  loosely  in  the  serum  of  the  sacs  ;  they  vary  in  size,  the 
largest  not  larger  than  small  beans  ;  generally,  they  are  ovoid, 
and  when  opened,  are  found  to  be  composed  of  many  lamina,  as 
in  the  layers  of  an  onion,  and  which  readily  separate.  This  form 
is  also  characterized  by  the  absence  of  pain.  The  best  descrip- 
tion and  plates  of  this  form  of  disease  is  found  in  Cooper's  work 
on  the  Breasts.  When  the  disease  has  advanced,  so  as  to  require 
treatment,  that  will  have  to  be  surgical,  the  breast  must  be 
removed,  inasmuch  as  the  great  mass  of  the  gland  is  diseased. 

1093.  The  third  species  of  hydatid  disease  of  the  breast,  is 
that  which  lias  been  called  animal  or  globular.  This  form  con- 
sists essentially  of  sacs  filled  with  similar,  but  smaller  sacs,  filled 
with  fluid,  having  no  vascular  connection  with  the  surrounding 
parts.  These  hydatids  are  not  confined  to  the  breasts,  but  are 
often  found  in  the  liver,  in  the  lower  part  of  the  abdomen,  in 
ovarian  tumors,  lungs,  the  brain,  around  the  heart,  etc.  The 
hydatid  is  contained  in  a  cyst,  which  is  surrounded  by  a  fibrinous 
effusion,  the  result  of  inflammation.  This  fibrinous  matter  is 
highly  vascular,  but  the  hydatids  are  not  immediately  connected 
therewith.  Cooper  describes  these  cysts  as  a  "  semi-diaphanous 
bag,  filled  by  a  clear  water,  and  it  is  uniformly  smooth  on  the 
inner  surface."  Having  no  opening  or  inlet,  it  is  nourished  by 
absorption  through  the  walls  of  the  cysts.  They  are  self-propa- 
gating, for  if  we  collect  the  fluid  of  a  sac,  we  shall  find  it  filled 
with  miniature  hydatids.  They  are  animalcules,  having  a  separate 
and  independent  existence,  and  propagate  on  their  interior  sur- 
face their  own  species.  They  are  sometimes  found  on  the  abdom- 
inal viscera  with  a  mouth  and  tail  added,  and  then  receive  their 
food  through  the  mouth  like  other  animals.  Sir  Astley  Cooper 
regards  them  as  the  true  link  between  the  vegetable  and  animal 
kingdom.  It  is  supposed  to  have  been  deposited  wherever  found, 
from  the  blood,  and  acting  as  a  foreign  body,  is  soon  inclosed  by 
the  adhesive  process. 


-50G  DISEASES     OF     WOMEN. 

1094.  The  proper  treatment  is  to  make  an  incision  im^    die 
hydatid  tumor,  discharge  the  contents  of  the  cysts,  and  then  it 
readily  heals,  and,  if  the  fluid  should  accumulate,  a  seaton  may 
be  passed  through  it,  so  as  to  set  up  sloughing.    Perhaps  it  would 
be   safer    and   more    economical    to    inject    the  cyst,   as  soon   as 
evacuated,  with  a  solution   of  Sesqui-Carbonate  of  Potash,    and 
thus  insure  a  radical  cure.    The  fourth  form  of  Mammary  Hydatids 
will  be  described  further  on. 

1095.  There    is   a    tumor  resulting   from    uterine    sympathy, 
mostly  found  in  females  from  seventeen  to  forty  years  of  age, 
which  is  denominated  Chronic  Mammary  Tumor.    It  is  mostly  found 
in  single  or  barren  women.     It  usually  springs  from  the  surface 
of  the  breast,  and  is  therefore  superficial  and  very  movable ;  it  is 
of  slow  growth,  painless,  generally,  though  sometimes  gives  rise 
to  a  sensation  of  rheumatic  pain  in  the  shoulder  ;   it  is  commonly 
more  tender  just  prior  to  the  recurrence  of  the  monthly  flow  of 
the  menses. 

1096.  These  tumors  seldom  acquire  a  weight  of  more  than  four 
or  five  ounces,  though  they  have  been  found  weighing  as  much  as 
one   pound.     They  will    exist   for    many  years,    then    disappear 
altogether,  and,  therefore,  are  in  no  sense  malignant.     The  tumor 
is  of  a  conglomerate  or  lobular  form,  and  the  name  of  lobulated 
Mammary  Tumor  has  been  suggested  by  Cooper.    Upon  dissection 
one  is  led  to  think  that  the  tumor  is  only  an  added  number  of 
lobules,  without  the  lactiferous  tubes.     It  differs  from  malignant 
tumors  of  the  breasts  by  the  youth  of  the  patient,  generally,  by 
the  absence  of  pain,  by  the  good  health  of  the  patient,  the  slow 
progress,  its  superficial  situation,  its  extreme  mobility,  and  lastly, 
its  lobular  Character,  which  is  at  once  revealed  to  the  sense  of 
touch. 

1097.  The  pressure  of  stays,  blows,  etc.,  encourage  the  devel- 
opment of  the  tumor,   but  the  real  cause  is  in  the  uterus.     We 
shall,  therefore,  be  at  once  led  to  the  principles   which  are  to 
govern  us  in  the  treatment  of  the  disease.     Every  function  must 
be  encouraged  to  normal  action.     The   digestion,   secretion   and 
excretions  must  be  inquired  into ;  but,  above  all,  the  state  of  the 
uterus  must  claim  special  consideration.     To  the  breast,  over  the 


DISEASES    OF    THE     BREAST.  507 

seat  of  the  tumor,  an  iodine  ointment  plaster  should  be  worn, 
unless  there  be  considerable  inflammation,  in  which  case  it  will  be 
best  to  employ  cooling  lotions  and  poultices  of  hops  and  bitter 
herbs.  We  must,  however,  not  expect  to  induce  their  absorption 
while  the  uterus  is  the  seat  of  irritation,  inflammation,  or  ulcera- 
tion.  The  disease  rarely  requires  an  operation,  and  it  will  be  our 
duty  to  make  its  character  known  to  the  patient,  who  is  always 
alarmed  as  to  the  possibility  of  its  terminating  in  cancer.  Mar- 
riage is  almost  sure  to  cure  it  when  it  occurs  in  single  women,  and 
a  due  attention  to  the  uterus  in  those  who  are  married  is  all  that 
is  required.  But  if  the  patient  is  determined  to  have  it  removed, 
no  operation  is  more  simple  and  certain  to  effect  a  radical  cure, 
no  possible  danger  attends  the  operation  in  any  way,  either  imme- 
diately or  remotely. 

1098.  In  certain  specific  inflammations  of  the  breasts,  Gelatine 
is  effused,  which  becomes  vascular  from  the  surrounding  parts. 
It  resembles  cartilage,  and  in  it  ossific   matter,  especially  phos- 
phate of  lime  is  deposited.     These  tumors  have  been  described  as 
Cartilaginous    and    Ossific    tumors.      The    pain    attending    these 
tumors  is  very  severe,  the  skin  is  warmer  than  natural,  the  tumor 
is  very  hard,  and  more  painful  before  than  after  menstruation. 
The  treatment  is  extirpation,  as  affording  the  only  relief. 

1099.  Adipose  tumors  are   frequently   formed  in  and   on  the 
mammary  gland.     These  tumors  may  grow  on  the  surface  covered 
only  by  the  skin,  or  they  may  be  merely  an  enlargement  of  those 
fatty  masses  which  occupy  the  interspaces  between  the  lobules. 
They  can  not  be  discussed,  and  the  better  plan  is  to  remove  the 
tumor  at  once,  which  may  be  readily  done.     Scrofulous  swellings 
of  the  breasts  are  sometimes  presented  to  the  surgeon,  but  they 
are  rare,  and  require  no  special  treatment. 

1100.  Sir  Astley  Cooper  describes  an  irritable  tumor  of  the 
breasts,  cases   of  which  I  have  seen  myself  in  several  instances, 
and  it  seldom  or  never  occurs  before  puberty.    When  the  complaint 
attacks  the  glandular  structure,  there  is  little  or  no  swelling  of  the 
breasts,  but  one  or  more  of  the  lobes  become  very  tender  to  the 
touch,  and  when  handled  gives  rise  to  pain,  which  does  not  subside 
for  aiany  hours.     This  pain  affects  the  entire  arm  and  shoulder, 


508  DISEASES     OF    WOMEN. 

and  generally  prevents  the  patient  from  lying  on  that  side  when 
in  bed.  It  may  also  affect  that  side  of  the  body  more  or  less. 
There  are  alternate  sensations  of  heat  and  cold  in  the  breasts; 
the  pain  is  neuralgic,  darting  here  and  there  along  the  nervous 
tracts — the  stomach  sympathizes,  vomiting  ensues,  the  pain  is 
more  acute  before  menstruation,  there  is  no  sign  of  inflammation, 
and  the  skin  retains  its  natural  color.  Both  breasts  may  be 
affected,  or  only  one,  or  even  a  part  of  either  one.  This  pain 
may  continue  for  months  or  years,  and  the  plan  of  treatment 
must  be  constitutional.  The  breasts  may  be  bathed  in  an  infusion 
of  Gelserninurn.  Poppy  and  Lobelia,  while  the  Gelsemin  or  Vera- 
trin  are  given  internally. 

1101.  But  occasionally  these  symptoms  are  associated  with  a 
tumor,   clearly   defined,    which    is    exquisitively   sensitive   to   the 
touch,  and  at  intervals  exceedingly  painful,  especially  before  men- 
struation.     They  vary  in  size,  but  do  not  usually  become  large. 
They  may  exist  in  this  painful  state  for  a  great  while,  when  the 
pain  may  cease,  and  the  tumor  finally  disappear.     The  treatment 
must  be  constitutional — and  so  ordered   as  to  lessen  the  nervous 
irritability  of  the  patient.     An  operation  is  by  no  means  admissi- 
ble, for  the  extraction  of  a  tumor  does  not  effect  a  cure ;    and 
more   than   one   case   has   occurred  where  this  has  been  clearly 
proven.      I  once,  in  my  earlier  practice,  committed  this  mistake, 
and  have  known  of  similar  errors  in  others.     The  mistake  is  a  sad 
•one,  and  we  can  not  exercise  too  much  care  in  diagnosing  this  as 
•well  as  other  similar  affections  of  the  breast.     The  space  at  my 
command  prevents  a  further  consideration  of  those  minor  affec- 
tions of  the  breasts,  and  I  shall,  therefore,  close  this  article  by 
presenting  briefly  some  views  of  cancer  of  the  breasts,  in  which 
the  profession  and  the  public  are  more  immediately  interested,  as 
the  disease  in  all  its  forms  is  a  source  of  great  dread,  and  gene- 
rally too  often  fatal  in  its  effects. 

1102.  Carcinomatous   or  cancerous  degeneration  of  the  mam- 
mary glands   has   thus   far  baffled   the  skill  of  the   medical  pro- 
fession.     It    is    true    that   here    and   there   we    sometimes    hear 
of  a   surgeon  who    has    had  much  success  in  the  treatment    of 
•Cancer,  but  until  recently,  as  the  disease,  exist  where  it  might. 


DISEASES     OF     THE     BREAST.  509 

was  considered  incurable,  it  was  thought  disreputable  to  adapt  its 
treatment  as  a  specialty,  and  hence,  too  many  physicians  have 
neglected  its  proper  study.  For  sixteen  years  I  have  made  this 
form  of  disease  a  special  study,  while  I  have  not  neglected  my 
general  surgical  and  medical  practice,  and  I  have  constantly 
endeavored  to  teach  the  classes  before  whom  I  have  lectured  for 
the  past  ten  years,  all  that  I  knew  in  relation  thereto ;  I  neither 
have,  nor  do  I  desire  to  make  any  secret  of  my  knowledge  in 
relation  to  the  treatment  of  cancer,  and  I  therefore  repudiate  the 
idea  of  being  merely  a  "Cancer  Doctor."  I  regard  cancer  as 

o  •/  O 

any  other  disease — one  phase  of  the  pathological  states  of  man, 
and  of  which  every  physician  should  be  informed.  It  wrould  be 
just  as  unphilosophical  to  cease  our  endeavors  to  understand  the 
nature  of  vomito,  because  we  can  not  always  cure  it,  as  to  neglect 
the  study  of  cancer,  because  the  profession  has  acknowledged  its 
inability  to  cure  it.  Such  an  admission  is  a  disgrace,  since  we 
know  that  in  various  parts  of  Europe  arid  America,  there  are 
practitioners  who  do  cure  cancer  in  all  its  forms,  and  what  one 
can  do  another  ought  to  try.  I  have  treated  several  hundred 
cases  from  all  parts  of  the  country,  and  while  I  have  sometimes 
failed  to  effect  cures,  especially  in  the  early  years  of  my  practice, 
I  am  proud  to  say  that  I  have  relieved,  radically,  hundreds  who 
will  sustain  this  declaration.  There  are  few  surgeons  in  America 
•who  have  had  so  extensive  a  practice  in  the  treatment  of  carci- 
nomatous  disease  as  myself,  and  therefore,  few,  if  any,  in  this 
country,  have  had  more  experience  than  myself.  If  I  shall  be 
instrumental  in  fixing  the  attention  of  the  profession  to  the  im- 
portance of  this  subject,  I  shall  have  been  amply  satisfied  for  the 
trouble  of  preparing  this  paper.  While  I  have  hundreds  of  cases 
that  might  be  detailed,  my  space  is  so  circumscribed,  that  I 
shall  be  compelled  to  confine  my  remarks  mostly  to  general 
principles. 

1103.  Carcinomatous  tumors  differ  from  every  tissue  found 
in  the  body,  which,  after  proper  development,  gives  rise  to  an 
ulcer,  which  in  its  extension  destroys  the  surrounding  parts. 
There  is  no  difficulty  in  identifying  carcinoma,  since  all  the 
varieties  depend  upon  constitutional  peculiarities,  the  tissues 


510  DISEASES      OF      WOMEX. 

which  surround  it,  the  stage  of  the  disorder,  etc.  The  anatomical 
revelations  of  cancer  are  so  peculiar  and  distinct  from  all  other 
tissues,  remove  every  doubt  as  to  its  character. 

1104.  There  are  five  prominent  forms  of  cancer  of  the  breasts  : 
Lobular  carcinoma,  intra-glandular  carcinoma,  encysted  carcinoma, 
carcinoma  of  the  nipple,  and  cutaneous  carcinoma. 

1105.  When    carcinoma   first  begins   to   develop,   one   form   is 
characterized  by  a  stony  hardness,  to  which  the   name  carcinoma 
fibrosum   is   given ;    but   when   the   tumor    is    soft,   imparting   an 
elastic  sensation,  it  is  called  carcinoma  medullare,  and  all  other 
forms  are,  at  most,  only  varieties  of  these  two. 

1106.  In  every  case,  the  tumor  will  have  acquired  some  size 
before  its  presence  is  detected.     When  examined,  the  tumor  feels 
hard,  or  it  will  be  perfectly  movable  beneath  the  skin.     At  this 
time  it  gives  no  pain,  Avas  accidentally  discovered ;   the  health  is 
good ;  but   after  a  few  weeks,  the  lump   has  grown,  lancinating 
pains  are  felt,  and  if  the  adipose  tissues  are  thin,  the  skin  is  seen 
to  be  elevated  by  the  tumor.     It  is   still  hard  to  the  touch,  and 
gives  a  sensation  of  roughness  to  the  touch.     If  the  growth  shall 
now  be  removed,  it  will  have  a  greyish-yellow  tint,  having  a  sort 
of  peduncle  by  which  it  was  connected  to  the  tissue  of  the  gland. 
Fibrous  lines,   radiating  from   the   tubercle,  extend  between  the 
subcutaneous  adipose  tissue  toward  the  skin — the  tubercle  itself 
looking  speckled  in  the  center,  owing  to  the  remains  of  the  ducts 
of  the  engorged  gland  tissue. 

1107.  After  a  few  more   weeks   or  months,  the  gland,   when 
again  examined,  will  be  found  to  have  enlarged,  it  is  more  painful, 
and   now  adheres   to  the  cutis,  which,  as  Birkett  says,  may  be 
"  slightly  puckered  in." 

1108.  The   adipose    tissue   covering    it   has    now  been  mostly 
absorbed,  and  the  attachment  between  the  tumor  and  skin  is  so 
perfect  that  one  readily  moves  the  other.     On   either  side  of  the 
tumor  the  skin  is  much  thicker  than   usual.     Unless  the  tumor 
shall  be  removed,  the  skin  becomes  harder,  and,  finally,  the  whole 
gland  has  disappeared,  to  give  place  to  the  tumor.     The  surface 
of  the  breasts  is  hard  and  rough,  while  the  skin  looks  as  though  it 
was  ready   to  burst    from    its    extreme   tension.     It   is   reddish, 


DISEASES     OF     THE     BREAST.  511 

shining,  and  looks  as  though  it  were  very  sensitive,  which,  strange 
to  say,  is  not  always  so. 

1109.  Another  stage  of  development  is  soon  established ;  the 
integuments    hegin    to    slough    away,   and    an    ulcer    is    at    once 
established.     Before  this  ulcer  has  been  completely  formed,  small 
cutaneous   eminences  appear,  the  center  of  which  decays,,  and  is 
thrown  off,  leaving  a  little  hole,  which  continues  to  enlarge,  until 
it  unites  with  others,  and  a  large  sloughing  ulcer  is  formed.     Or 
the  ulcer  may  form  by  scaly  cracks  from   which  an  oozing  takes 
place,  and  these  cracks  uniting,  result  in  a  foul  ulcer.     Sometimes 
the   development    seems   to   be    suddenly   arrested,    but    such    an 
occurrence  is  at  all  times  an  unfavorable   circumstance,  since  the 
disease  is  at  work  on  new  tissues,  and   suddenly  we  find  every 
eymptom  greatly  aggravated. 

1110.  Soon  after  the  attachment  of  the  skin  to  the  tumor,  the 
axillary  glands   become   affected ;   prickling   of   the   skin   in   that 
region  increases ;   oedema  of  the  arm  follows ;  arid  great  pain  is 
felt  from  any  motion  involving  the  action  of  the  thoracic  muscles, 
as  in  breathing,  which  is  often  very  painful.     A  dull  leaden  hue 
characterizes  the  aspect  of  the  patient ;  the  countenance  is  uneasy 
and  depressed ;  the  strength  fails ;  the   scent  nauseates  her ;  she 
has  pain  in  the  bowels,  and  the  patient  sinks  under  her  multiplied 
maladies. 

1111.  Carcinoma  is  rarely  developed  in  the  mammary  gland 
before  the  age  of  twenty-eight,  though  it  is  sometimes  found  as 
soon  as  the   establishment  of  the  function  of  menstruation,  and 
some  few  cases  are  reported  where  it  occurred  in  children.     From 
28  to  50  years   it  is   very  common.     It  is   sometimes  found  in 
women  who  have  attained  the  age  of  90  years.     It  may  attack 
married  or  single  women,  those  who  are  prolific  or  those  who  are 
sterile.     Celibacy  seems  to  favor  the  disease,  notwithstanding  the 
figures  of  Dr.  Lever  to  the  contrary.     For  while  the  percentage 
in  married  is  to  its  percentage   in  single  women,  as  85  to  6,  we 
must  remember  that  the  percentage  of  married  to  single  women  is 
even  greater. 

1112.  There  is,  evidently,  a  cancerous  cachexia,  but  it  is  very 
difficult  to  describe  it.     It  may  be  known  only  by  experience,  in 


512  DISEASES     OF    WOMEN. 

which  it  will  be  observed  that  such  women  are  those  who  are- 
impressible  to  misfortune,  and  who  have  had  much  real  or  imagi- 
nary trouble. 

1113.  Those  who  have  a  strumous  diathesis  are  most  subject  to 
cacoplastic  deposits,  but  to  point  out  any  signs  which  would  enable 
us  to  say  that  any  woman  was  liable  to  or  free  from  the  horrors 
of  carcinomatous  disease,  is  out  of  the  question,  in  our  present 
state  of  knowledge.     Cancer  is  a  local  manifestation  of  a  consti- 
tutional  dyscrasia,  and  we   shall  generally  find,  along  with  the 
earliest  manifestations  of  the  disease,  defective  nutrition. 

1114.  To   be    better    enabled   to   comprehend   the   disease,  its 
development  has  been  divided  into  stages,  which,  however,  answers 
the  purposes  of  convenience  only  inasmuch  as  the  whole  process 
is  a  degeneration  from  the  outset,  and  the  constant  tendency  is  to 
a  fatal  termination.     At  first  the  tumor  is  found  small  and  rolling 
like  a  stone  under  the  integuments,  and  is  generally  situated  on 
the  peripheral  extremity  of  a  lobe.      This  new  growth  may  be 
attached  to  the  surface  of  the  gland,  between  it  and  the  integu- 
ments, and  under  or  in  the  subcutaneous  adipose  tissue.     In  this 
event,  it  is  called  extra-glandular;  or  when  it  rises,  as  it  some- 
times does,  from  the  very  center  of  the  gland,  it  is  called  intra- 
glandular.     In  that  event,  it  is  situated  immediately  behind  the 
nipple  and  areola.     When  it  becomes  attached  to  the  skin,  it  is 
said  to  have  passed  into  the  second  stage.     The  adipose  tissue 
has  been  displaced,  the  tumor  extends  right  and  left,  and  greedily 
contaminates  the  surrounding  parts.     When  the  cutis  begins  to 
thicken,  grow  red  and  glossy,  the  third  stage  is  said  to  have  been 
reached.      When    the    tumor   becomes   attached   to   the   thoracic 
walls,  it  is  said  to  have  entered  on  the  fourth  stage.     In  the  first 
of  these  stages  the  patient  complains  of  no  pain,  and  this  is  so 
true,  that  she  admits  considerable  manipulation  without  the  mani- 
festation of  any  uncommon  sensitiveness.    When  it  happens  to  be 
in  contact  with  the  minute  branches  of  the  inter-costal  nerves,  it 
is  more  painful.     The  pain  is  of  the  lancinating  kind,  and  is  not 
confined  to  the  gland.     The  pain,  no  doubt,  arises  from  stretching 
the  nervous  filaments,  and  hence  the  pain  is  often  referred  to  the 
sentient  extremities    of  the   nerve    whose   trunk  had  been   thus 


DISEASES     OF     TITE     BREAST.  513 

stretched.  While  the  pain  in  some  cases  is  not  intolerable,  in 
other  instances  it  is  excrutiatingly  severe.  The  external  charac- 
teristics do  not  become  clear  until  the  third  stage  has  been 
reached,  when  an  oozing  takes  place  from  the  cuticular  surface, 
which,  drying,  forms  a  scab ;  in  others,  a  fissure  in  the  skin 
appears,  which  at  first  may,  or  may  not,  be  attended  with  redness. 
At  last,  however,  a  redness  surrounds  the  scab  or  fissure,  as  the 
case  may  be,  the  discharge  is  more  copious,  and  soon  the  surface 
begins  to  excoriate,  which  is  evidently  a  result  of  carcinomatous 
contamination. 

1115.  The  fourth  stage  is  that  of  necrosis,  more  particularly. 
Development  does  not  cease  here ;  but  the  earlier  developments 
die,  and  fall  off.     As  now  seen,  the  ulcer  is  a  frightful,  a  gap- 
ing, and  eroded  sore,  the  edges  of  Avhich  are  elevated,  with  deeply 
excavated,    and  irregular   surfaces,  from   which   there    is  poured 
out  a  most  offensive  ichor,  which  is  the  debris  of  the  decomposed 
carcinomatous  tissue,  mixed  with  serum,  serous  fluid,  and  blood. 
The  nipple  is  often  depressed,  a  circumstance  which   may  arise 
from  the  elevation  of  the  surrounding  skin,  or  from  the  tension 
made  on  the  tubes  attached  to  it  by  the  growth  behind  it. 

1116.  It  would  be  desirable  to  determine,  if  possible,  the  pro- 
bable duration  of  the  disease,  but  such  an  attempt  would  be  futile. 
Sometimes  death  will  take  place  in  four  months  ;   again,  it  may 
last  many  years ;  but,  from  my  experience,  I  should  be  led  to  say 
that  the  disease  will  run  its  course  in  three  years,  on  an  average. 
There  is  a  fact  connected  with  the  second  stage  of  carcinomatous 
growths   of  the   breasts    to   which    I  must  make   some   allusion, 
I   refer  to    the   implication    of   the   axillary    lymphatic    glands, 
which  actually  undergo  an  organic  change,  and  while  I  do  riot 
profess  an  ability  to  give  a  rational  explanation  of  the  circum- 
stance, I  must  nevertheless  remark,  that  I  think  the  fact  is  an 
index  to  the  constitutional  management  of  the  disease.     The  con- 
stitutional effects  of  these  various  stages  must  claim  our  attention 
briefly.     Generally,  when  the  tumor  appears  about  the  "change 
of  life,"  we  shall  be  apt  to  learn  that  some  common  malaise  has 
been  experienced.     The  patient  does  not  begin  to  feel  ill  until  the 
second  and  third  stages   have  been  established.     Her  sleep  will 

33 


514  DISEASES. OF     TFOMEN. 

then  be  disturbed,  she  is  duller  than  in  ordinary  health;  she  has 
nausea  in  the  morning,  and  usually  constipation  all  the  time.  All 
these  symptoms  are  intensely  aggravated  during  the  fourth  stage. 
The  arm  of  the  affected  side  swells,  becomes  O3dematous,  and 
painful  on  slight  motion ;  the  breathing  is  difficult  and  the  patient 
is  often  constantly  sick  at  the  stomach.  Racking  pains  are  felt 
in  the  bones,  jaundice  supervenes,  and  great  constipation  is  often 
experienced. 

1117.  Of  the  treatment  I  shall  be  brief,  for  I  have  already 
occupied  my  allotted  space.  It  is  universally  admitted  that  the 
mere  removal  of  the  tumor  with  a  knife  will  not  effect  a  radical 
cure.  If  a  cure  is  to  be  effected  in  this  way,  it  is  when  the  tumor 
is  in  its  first  stage,  and  a  large  part  of  the  sound  tissues  sur- 
rounding it  have  been  removed  therewith.  It  is  evident  that  no 
operation  of  any  kind  should  be  attempted  until  the  constitution 
is  in  the  best  possible  state — not  until  every  function  is  in  a  state 
of  activity.  The  disease  is  both  constitutional  and  local,  and  in 
its  treatment  our  remedies  must  be  both  general  and  special. 
For  this  reason,  when  a  patient  comes  to  me  for  treatment  it  is 
my  first  care  to  put  her  on  a  properly  nutritious  diet;  to  regulate 
the  functions  of  the  skin,  liver,  kidneys,  etc.,  to  effect  which 
objects,  of  course  a  variety  of  remedial  agents  are  to  be  employed. 
Comp.  Syrup  of  Stillingia,  Iodide  of  Potassium,  and  Prussiate  of 
Iron  are  usually  given,  along  with  such  other  agents  as  may  seem 
to  be. indicated,  as  narcotics  in  extreme  irritability,  stimulants  in 
great  depression,  etc. ;  particularly  should  we  look  to  the  digestive 
functions,  and  when  we  have  removed  the  anemic  habit  of  the 
patient,  she  is  then  ready  for  an  operation.  For  the  sake  of  econ- 
omy the  patient  is  put  under  the  influence  of  chloroform,  and  the 
entire  diseased  mass  is  at  once  removed  with  the  knife,  after  which 
I  usually  cover  the  surface  with  some  tonic  escharotic,  as  Chloride 
of  Zinc,  which  seems  to  act  more  rapidly  and  greedily  on  the  car- 
cinomatous  tissue.  This  is  followed  by  poultices  to  slough  the 
surface ;  and  again,  time  after  time,  while  a  visible  shred  of  th3 
diseased  tissue  remains,  this  plan  is  followed,  during  which  time 
the  system  is  toned  up  to  the  highest  pitch,  and  the  functions  are 
all  closely  watched.  In  this  way,  by  the  union  of  constitutional 


DISEASES     OF     THE     BREAST.  515 

and  local  treatment,  if  the  constitutional  stamina  is  good,  we  shall 
often,  nay,  if  we  proceed  judiciously,  nearly  always  effect  a  cure. 
Nor  is  the  cure  temporary,  as  can  be  demonstrated  by  cases  now 
in  this  city,  whom  I  discharged  ten  or  twelve  years  since.  As 
every  case  will  differ  from  the  common  type,  we  shall  be  com- 
pelled to  vary  our  plan  of  treatment.  What  I  have  thus  written 
I  know  by  experience,  and  I  ask  that  attention  to  the  subject 
which  its  great  importance  demands.  The  practice  here  given 
has  been  pursued  by  many  who  have  witnessed  my  operations  and 
attended  1113-  clinic  lectures,  and  1  am  proud  to  say  with  great 
success. 


TREATMENT  OF  DISEASES  OF  THE  BREAST. 

Acute  Inflammation. — Among  the  troubles  of  child-bearing  there 
are  none  that  are  more  annoying  than  diseases  of  the  breast,  and 
none,  I  am  glad  to  say.  more  amenable  to  treatment.  An  early 
knowledge  of  the  trouble,  and  prompt  means  for  its  relief,  become 
necessary  if  we  expect  the  greatest  success,  and  the  physician 
fails  to  do  his  duty  that  allows  disease  to  progress  without  notice 
and  treatment. 

It  is  especially  to  be  observed  that  all  rubbings  of  the  breast, 
either  before  or  after  delivery,  with  the  crude  idea  of  "  softening 
it,"  or  "  toughening  it,"  are  to  be  avoided.  The  application  of 
Pond's  Ext.  of  Hamamelis  to  the  nipple  and  areola  is  permissible, 
and  may  sometimes  be  beneficial  in  lessening  the  irritability  of 
the  nipple;  and  the  applicat.ion  to  the  breast  may  sometimes  re- 
lieve irritation  and  lessen  sensitiveness.  But  if  consulted  about 
sensitive  breasts  before  delivery,  we  can  not  do  better  than  to 
prescribe  small  doses  of  Phytolacca,  and  if  necessary  make  a  local 
application  of  the  same. 

"  Milk  fever  ''  is  sometimes  attended  with  irritation,  fullness  and 
engorgement  of  the  breasts — "caking" — which  may  go  on  to 
inflammation.  The  administration  of— R  Tinct.  Aconite,  gtt.  v; 
Tinct.  Phytolacca,  gtt.  xx  ;  Water,  ^iv.,  a  teaspoonful  every  hour, 
will  usually  give  prompt  relief.  In  some  cases  the  severe  after- 
pains  call  for  Macrotys,  and  it  may  be  added  to  the  mixture. 

Proper  support,  with  sufficient  freedom,  should  be  looked  to, 


516  DISEASES     OF     WOMEN. 

and  the  ordinary  corset  with  whale-bones  making  pressure  uponr 
or  sticking  into  the  breast,  avoided.  It  is  possible  to  have  an  un- 
derwaist  cut  so  as  to  fit  the  chest  and  the  breasts,  and  give  this 
support,  and  this  should  be  named  to  the  mother.  It  may  also 
be  made  of  such  material  as  will  give  the  required  warmth. 

With  the  first  announcement  of  the  symptoms  of  inflammation 
of  the  breast  we  put  the  patient  upon  the  use  of  Phytolacca, 
either  alone  or  with  the  sedative.  Aconite,  if  there  is  vascular 
disturbance,  Macrotys  if  associated  with  uterine  tenderness  and 
pain,  Bryonia  if  there  is  costal  pain  and  soreness,  Iris  if  there  is 
fullness  of  the  thyroid,  and  other  remedies  as  they  may  be  indi- 
cated. It  will  not  do  to  say  that  Phytolacca  will  cure  all  cases  of 
inflammation  of  the  breasts.  Without  other  indications  than 
mammary  irritation  and  determination  of  blood,  it  is  sufficient, 
but  other  lesions  require  other  remedies.  If,  for  instance,  the 
lochial  discharge  was  fetid,  we  would  want  chlorate  of  potash  ; 
if  the  tongue  was  heavily  coated  and  pallid,  sulphite  of  soda.  etc. 

In  the  commencement  of  mammary  inflammation,  I  frequently 
paint  the  affected  part  with  tinct.  Veratrum.  or  Veratrum  and 
Aconite.  It  msiy  be  used  in  the  full  strength  or  diluted  with  one 
or  two  parts  of  glycerine  or  water.  It  is  better  to  limit  the  appli- 
cation to  a  space  not  larger  than  three  inches  in  diameter,  and  the 
mother  or  nurse  should  be  cautioned  against  letting  the  lotion 
come  in  contact  with  the  nipple,  or  the  child's  mouth  come  in 
contact  with  that  portion  of  the  breast  to  which  it  has  been 
applied.  In  other  cases  when  the  inflammation  is  not  so  active, 
we  may  use  a  lotion  of  equal  parts  of  tinct.  Phj'tolacca.  glycerine 
and  water;  or  when  there  is  evident  congestion  a  portion  of  tinc- 
ture Belladonna  may  be  added. 

Fomentations  and  poultices  are  to  be  avoided  in  the  early  stage 
for  without  these  we  may  reasonably  expect  resolution  in  a  large 
number  of  cases,  whilst  if  the  bi-east  is  poulticed,  suppuration  is 
a  common  result.  Even  when  suppuration  is  unavoidable,  it  is 
best  to  use  poultices  with  caution,  or  avoid  them  altogether,  for 
the  less  suppuration  we  have  the  better  it  will  be  for  the  breast 
and  the  mother.  I  have  continued  the  Aconite  and  Veratrum  to 
the  extent  of  relieving  the  acute  suffering,  and  Phytolacca  in  the 
iaterim,  through  the  entire  process  of  suppuration,  until  the 
breast  had  healed. 


DISEASES     OF     THE     BREAST.  517 

If  we  use  a  poultice,  nothing  will  be  better  than  a  strong  infu- 
sion of  Ph_ytolacca  (the  fresh  root  if  it  can  be  obtained),  thick- 
ened with  wheat  bran.  In  place  of  this,  a  simple  flax-seed  poul- 
tice will  prove  as  good  as  anything,  or  a  couple  of  folds  of  lint 
wetted  with  warm  water,  and  sprinkled  with  tincture  of  Stra- 
monium. 

With  the  appearence  of  pus  near  the  surface,  determined  by 
yellow  discoloration,  or  by  fluctuation,  or  the  deep  throbbing  pain 
when  the  pus  is  deep-seated,  it  is  best  to  give  it  an  exit  with  the 
lancet.  The  suffering  of  the  mother  at  this  time  is  very  severe, 
local  applications  do  no  good,  and  if  narcotics  are  given  the  gen- 
eral health  must  suffer.  The  patient  dreads  the  knife,  it  is  true, 
and  we  dislike  to  use  it,  but  it  gives  prompt  relief  like  pulling  a 
tooth,  and  if  the  physician  has  experimented  with  the  scalpel 
until  he  can  make  a  rapid  and  skillful  incision  the  pain  is  not  so 
very  great.  But  save  me  from  your  bungling  doctor,  who  holds 
his  knife  unsteady,  and  saws  through  the  tissues  like  an  unskill- 
ful carver  trying  to  find  the  joint  of  a  fowl.  If  such  a  one  should 
read  this,  I  advise  him  to  buy  an  old-fashioned  spring  lancet  for 
his  operation,  and  that  will  go  quick. 

The  incision  should  always  be  made  in  the  direction  of  the 
milk  ducts — from  the  nipple  to  the  circumference  of  the  breast, 
and  never  across  them.  This  may  seem  a  trivial  matter  to  the  be- 
ginner, but  it  is  a  most  serious  one  to  the  patient,  for  the  cross 
incision  may  obliterate  the  milk  ducts,  and  cause  disease  with 
each  successive  child. 

If  the  inflammation  progresses  steadily,  and  the  breast  is  very 
large  and  heavy,  its  weight  may  be  sufficient  to  continue  the  dis- 
ease, and  occasion  much  suffering.  I  have  already  called  atten- 
tion to  the  necessity  of  support  for  the  healthy  breast ;  the  dis- 
eased breast  requires  it  still  more.  A  handkerchief  may  be  so 
arranged  around  the  neck,  in  the  form  of  a  sling,  as  to  give  a 
very  good  support,  but  it  is  better  obtained  by  having  a  piece 
of  stout  muslin  cut  to  fit  the  breast.  Even  this  may  not  be  suffi- 
cient, and  we  use  adhesive  strapping,  not  only  to  give  support, 
but  to  compress  the  enfeebled  tissues.  I  have  seen  prompt  relief 
given  by  the  application  of  strips  when  the  patient  had  formerly 
been  suffering  severely,  and  a  termination  by  resolution  or  lim- 
ited suppuration,  when. otherwise  there  would  have  been  exten- 


518  DISEASES     OF     WOMEN. 

give  destruction  of  tissue.  The  reader  will  recollect  the  treatment 
of  orchitis  by  strapping,  and  will  use  the  adhesive  plaster  here 
in  the  same  way  and  for  the  same  purpose. 

It  must  not  be  forgotten  that  when  pus  has  formed  and  the 
abscess  opened,  we  are  not  yet  through  with  our  case,  nor  the 
patient  with  her  trouble.  Other  points  of  irritation,  engorge- 
ment and  inflammation  may  appear,  and  before  the  disease  has 
run  its  course  the  breast  may  be  honeycombed  with  fistulous 
pipes  from  small  abscesses.  I  do  not  think  this  is  likely  with  the 
treatment  named,  and  when  the  breast  is  cared  for,  but  is  rather 
due  to  neglect  and  want  of  knowledge.  See  that  the  breast  has 
constant  support ;  use  the  local  application  named  to  an}- point  of 
irritation  that  shows  itself;  give  Phytolacca  internally,  and  use 
euch  means  as  may  be  necessary  to  restore  the  general  health, 
and  we  will  have  an  end  to  the  disease,  and  a  good  condition  of 
the  breast. 

In  some  cases  neither  the  abscesses  nor  fistulae  have  any  incli- 
nation to  heal,  and  the  breast  remains  in  a  very  unpleasant  con- 
dition. Here  we  must  think  of  some  local  means  that  will  free 
the  breast  from  the  diseased  tissues,  and  stimulate  the  structures. 
At  tirst  I  use  a  wet  dressing  of — R  Salicylic  Acid,  Borax,  aa.  3j. 
to  3ij.;  Water,  Oj  ;  and  even  wash  the  abscesses  out  with  it  if  ne- 
cessary. But  if  still  more  sluggish,  with  the  debris  of  old  tissues 
lining  the  abscess,  there  is  nothing  better  than  the  injection  of 
sesqui-carbonate  of  potash  (saturated  solution),  followed  by  the 
dressing  above  named. 

Chronic  Inflammation. — Chronic  inflammation  is  usual^  the  re- 
sult of  the  acute  which  has  terminated  in  suppuration,  as  already 
described.  If  properly  treated  as  above  described,  I  do  not  think 
any  inflammation  will  continue,  though  for  some  time  there  may 
be  local  indurations,  and  such  adhesions  may  be  formed  as  will 
cause  trouble  when  the  breast  again  comes  into  use.  But  if  the 
old  methods  of  poultices  and  frequent  lancing  is  followed,  we  may 
not  only  have  serious  lesion  of  structure,  but  a  condition  of 
chronic  inflammation  continuing  for  years. 

Even  in  this  case  I  have  great  faith  in  Phytolacca  as  a  remedy, 
and  administer  it  internally  and  apply  it  locally.  Of  course  it  is 
not  the  only  remedy,  as  we  may  find  use  for  any  of  those  we  have 
studied,  if  we  carefully  observe  the  indications.  The  breast  should 


DISEASES     OF     THE     BREAST.  519 

alwa}'s  have  a  well  adjusted  support,  and  be  protected  against 
sudden  changes  of  temperature  and  other  causes  of  irritation. 
In  some  cases  strapping  will  answer  a  good  purpose. 

If  there  lias  been  considerable  deposit,  the  gland  being  greatly 
enlarged,  and  its  circulation  enfeebled,  I  would  recommend  the 
local  application  of  the  Uvedalia  ointment,  or  one  part  ot  the 
tincture  to  four  parts  of  water  and  Glycerine.  The  old  Mayer's 
ointment  proved  an  excellent  application  in  some  of  these  cases, 
and  in  some  the  ointment  of  iodide  of  lead  was  of  service. 

With  fistulse  and  the  remains  ot  old  abscesses  nothing  is  so  good 
as  the  thorough  injection  of  a  saturated  solution  of  sesqui-carbo- 
nate  of  potash,  and  a  wet  dressing  of  salicylic  acid  and  borax. 

Disease  of  the  Nipple. — -"  Sore  Nipples  "  are  among  the  unpleas- 
antnesses of  child-bearing,  and  frequently  give  mother,  nurse,  and 
doctor  a  great  deal  of  annoyance.  This  may  be  provided  against 
in  some  cases,  by  care  of  the  nipple  and  breasts  the  last  weeks  of 
pregnancy  and  when  the  child  commences  to  nurse.  The  use  of 
Pond's  Hamamelis  before  confinement  has  been  thought  to  harden 
the  nipple,  and  prevent  after  trouble,  but  I  prefer  the  lotion  of 
borax  and  salicylic  acid,  or  the  tincture  of  Penthorum  one  part 
to  glycerine  and  water  five  parts. 

The  first  symptoms  of  soreness  of  the  nipple,  or  soreness  of  the 
mouth  of  the  child,  should  be  met  by  the  administration  of  Phy- 
tolacca  to  the  mother  in  the  one  case,  to  the  child  and  mother  in 
the  other.  It  is  a  little  singular  that  the  sore  mouth  of  the  child, 
shown  by  its  crying  when  put  to  the  breast,  may  be  the  very  first 
intimation  of  the  sore  nipple  which  is  sure  to  follow,  and  the 
physician  will  be  surprised  to  find  how  wide  the  range  of  Phyto- 
lacca  is  in  these  cases,  and  how  prompt  and  certain  its  action. 

Insist  that  the  child  be  nursed  at  proper  intervals  of  two  to 
three  hours,  and  that  the  breasts  be  drawn  alternately,  and  not 
allowed  to  be  too  greatly  distended.  If  the  nipple  sinks  in,  and 
is  difficult  for  the  child  to  take  hold  of,  use  a  good  breast-pump 
to  draw  it  out.  But  in  all  cases  be  sure  that  the  nipple  is  properly 
dried  after  nursing,  and  covered  with  a  fold  of  soft  cloth  when 
the  breast  is  returned  under  the  clothing. 

If  I  was  asked  for  the  very  best  wash  in  these  cases,  I  should 
answer,  a  lotion  of  borax,  or  borax  and  salicylic  acid.  I  prescribe 
the  first  as  follows:  R  Borax,  gr.  x.;  Glycerine.  3j..  Eose  Water, 


620  DISEASES     OF     WOMEN. 

Jiij..  The  second  maybe  used  in  the  proportions  already  named. 
A  very  good  prescription  in  some  cases  is — fy  Chloral,  gj.;  Glyce- 
rine, §j.;  Rose  Water,  giij.;  used  as  above.  There  are  many  pre- 
scriptions for  this  purpose,  but  my  experience  has  shown  that  in 
a  multitude  of  prescriptions  there  is  no  wisdom.  Especially  avoid 
ail  ointments  or  "  salves,"  or  anything  containing  fatty  matter. 

If  there  is  local  ulceration,  or  painful  and  suppurating  fissures, 
nitric  acid  with  the  pine  pencil  may  be  used  to  advantage,  asso- 
ciated with  the  other  treatment.  I  do  not  like  nitrate  of  silver. 

But  the  remedy  in  a  large  majority  of  cases  will  be  found  in 
the  lead  nipple  shield,  which  should  be  continually  worn.  It  is 
easily  made  by  heating  out  a  piece  of  lead  into  a  thin  sheet,  and 
then  indenting  it  with  a  piece  of  wood  formed  to  the  size  and 
shape  of  the  nipple.  It  should  be  moulded  so  as  to  fit  accurate!}-, 
and  the  edges  may  be  trimmed  so  that  it  will  extend  over  the 
breast  an  inch  from  the  nipple.  Being  thin  the  weight  is  no 
objection,  and  it  protects  the  nipple  and  is  at  the  same  time  the 
very  best  remedy  for  the  ulceration. 

Benign  Growths. — The  difficulties  of  diagnosis  have  already  been 
named,  and  the  fact  that  many  benign  growths  are  mistaken  for 
cancer,  and  the  breast  removed  in  consequence.  If  the  reader 
will  bear  in  mind  that  the  malignant  or  cancerous  growth  appro- 
priates the  tissues  of  a  part  to  its  own  use;  that  it  is  in  fact  a 
degeneration  of  the  tissue ;  and  that  the  benign  growth  is  always 
distinct  from  the  natural  tissues,  an  outgrowth  from  them,  and 
never  appropriated  by  them ;  we  will  have  the  best  grounds  for 
a  correct  diagnosis.  If  we  can  determine  that  a  tumor  is  separate 
from  the  glandular  structure,  movable  on  the  wall  of  the  chest, 
and  that  the  skin  moves  freely  over  it,  we  have  reason  to  believe 
that  it  is  benign.  This  is  strengthened  if  the  surface  of  the  growth 
is  smooth,  it  is  of  equal  consistence,  and  it  is  free  from  pain,  ex- 
cept that  which  comes  from  pressure  or  weight. 

In  some  women,  from  the  age  of  35  to  50  the  breasts  are  so 
freed  from  the  earlier  deposits  of  fat,  that  the  glandular  structure 
is  felt  very  distinctly,  and  when  well  developed  it  may  seem  like 
a  nodulated  growth,  or  a  series  of  these  growths.  I  have  seen 
three  cases  of  this  kind  in  which  women  were  frightened  by  the 
thought  that  they  had  cancer.  In  one  case  it  was  diagnosed  as 
cancer  by  two  physicians. 


DISEASES     OF     THE     BREAST.  521 

Having  determined  that  our  patient  has  a  benign  growth,  the 
next  question  is  as  to  its  treatment.  Local  applications  to  the 
surface  are  absolutely  of  no  use,  and  neither  is  internal  treatment. 
If  the  tumor  has  a  very  slow  growth,  and  does  not  give  much 
annoyance  by  pressure,  we  let  it  alone.  But  if  it  is  decided  to 
remove  it,  we  have  a  very  simple  operation.  An  incision  is  care- 
full)'  carried  down  to  the  growth  where  it  can  best  be  reached, 
not  dividing  the  milk  ducts  if  possible  to  avoid  it,  and  the  growth 
then  enucleated  with  the  handle  of  the  scalpel  Or  with  the  finger. 
When  the  growth  has  a  fibrous  capsule  and  fluid  contents,  a  care- 
less incision  may  cut  through  the  capsule,  discharging  the  con- 
tents, and  make  the  operation  a  failure. 

If  it  is  a  simple  growth,  we  may  bring  the  parts  together  and 
have  it  heal  by  first  intention  ;  but  if  we  have  reason  to  believe 
it  is  a  recurrent  fibroid,  Ave  are  careful  to  remove  the  base  from 
which  the  growth  sprang,  and  leaving  the  wound  open  heal  it  by 
suppuration.  These  operations  about  the  breast  are  so  simple 
that  anyone  can  perform  them  with  safety,  if  he  studies  his  case 
well. 

Malignant  Growths. — The  evidence  of  malignancy  is  sometimes 
so  clearly  marked  that  no  one  can  make  a  mistake;  but  at  others 
it  is  very  difficult  to  make  a  diagnosis.  If  the  structure  of  the 
gland  is  very  evidently  being  appropriated  by  the  growth,  it  is 
cancer.  This  can  almost  always  be  determined  when  it  comes  to 
the  surface,  and  we  witness  the  gradual  change  in  the  skin.  The 
peculiar  pain  is  also  characteristic — twitching,  sticking,  darting, 
crawling,  alwaj's  radiating  from  a  common  center  to  the  circum- 
ference of  the  gland  ;  the  gradual  agglutination  and  adhesion  of 
parts,  until  finally  the  growth  is  fixed  ;  its  uneven  surface,  and 
unequal  resistance  to  pressure;  and  finally  the  enlargement  of 
the  lymphatic  glands  of  the  axillae,  and  the  impairment  of  the 
general  health — cancerous  cachexia. 

Having  diagnosed  our  case  as  one  of  cancer,  we  wish  to  deter- 
mine the  best  treatment.  We  have  first  to  determine  whether 
the  growth  shall  be  removed,  or  whether  the  treatment  shall  be 
palliative,  and  if  it  is  decided  to  remove  it,  we  wish  to  determine 
the  best  method. 

We  will  decide  to  remove  the  cancerous  growth  when  the  mam- 
gland  is  freely  movable  on  the  chest,  and  when  there  is  no, 


522  DISEASES     OF     WOMEN. 

or  very  little,  engorgement  of  the  axillary  lymphatic?.  If  the 
growth  has  formed  an  attachment  to  the  pectoral  muscles,  it  is  an 
unpromising  case,  as  it  is  when  there  is  much  disease  of  the  lym- 
phatic glands,  and  the  unpleasant  waxy  sallowness  of  skin  that 
marks  the  cancerous  cachexia.  Whether  the  cancer  is  open — sup- 
purating— or  still  covered  by  the  integument,  makes  little  differ- 
ence, but  the  more  rapid  its  growth  the  more  unfavorable  the 
prognosis. 

Having  determined  to  remove  it,  we  must  next  choose  the 
method.  If  the  growth  is  entirely  free,  not  having  formed  attach- 
ments to  the  muscles  below  or  the  skin  above,  excision  of  the 
gland  is  decidedly  preferable.  If  it  has  appropriated  a  portion 
of  the  skin,  and  is  suppurating,  we  may  still  excise  the  breast,  or 
we  may  remove  it  with  chloride  of  zinc  or  arsenious  acid.  Hav- 
ing determined  on  excision  of  the  breast  as  the  better  method, 
•we  explain  to  the  friends  that  we  select  this  because  it  is  the  speed- 
iest and  least  painful  method,  but  that  to  prevent  a  return  of  the 
growth  in  the  cicatrix,  we  heal  it  by  suppuration,  as  an  open 
wound,  and  do  not  bring  flaps  of  skin  over  it  for  speedy  union, 
as  generally  practiced.  There  seems  to  be  an  antagonism  between 
the  suppurative  process  and  cancerous  growth — the  pus  cells 
replacing  the  cancerous  cells,  so  that  this  healing  by  suppuration 
becomes  an  important  part  of  the  treatment. 

Any  one  who  has  the  least  nerve  arid  moderate  skill  with  the 
knife,  can  perform  this  operation.  The  breast  is  lifted  with  the 
hand,  and  a  sweeping  incision  made  around  it,  commencing  next 
the  axilla,  and  dividing  the  upper  and  interior  part  last,  so  that 
•we  may  speedily  take  up  the  mammary  arteries.  The  gland  is 
dissected  from  the  pectoral  muscles,  and  we  leave  no  engorged 
tissue  if  we  can  avoid  it.  It  is  hardly  necessary  to  say,  that  any 
enlarged  lymphatics  in  the  axilla  should  be  removed,  for  if  they 
are  left  the  disease  is  sure  to  re-appear  in  the  cicatrix  or  the  axilla. 
For  the  first  day  we  use  a  simple  water  dressing,  or  add  a  small 
portion  of  borax  and  salicylic  acid  to  it.  Then  we  make  our  anti- 
septic dressing  a  little  stronger,  or  in  three  or  four  days  we  may 
dress  it  with  mild  zinc  ointment.  Every  day  when  it  is  dressed 
we  examine  the  surface  carefully  to  see  if  there  are  any  large  or 
discolored  granulations,  or  any  sensitive  points.  If  we  find  either 
we  sprinkle  the  surface  with  finely  powdered  sulphate  of  zinc,  or- 


DISEASES     OF     THE     BREAST.  523 

apply  the  chloride  of  zinc  paste  to  the  spots,  and  burn  them  down. 
Thus  with  careful  attention  we  see  the  wound  gradually  close  up 
by  granulation,  and  at  last  a  firm  cicatrix  is  formed. 

Chloride  of  zinc  is  the  escharotic  in  common  use  by  Eclectic 
physicians,  and  may  be  so  applied  as  to  destroy  the  growth  and 
effect  a  cure.  I  should  prefer  to  use  it  in  epithelial  cancer,  or 
when  the  growth  being  near  the  surface,  had  involved  the  skin, 
and  when  it  was  still  of  moderate  size.  Our  object  here  should 
be  a  rapid  destruction  of  the  diseased  tissues,  for  not  only  is  the 
application  very  painful,  but  it  excites  inflammation  of  adjacent 
tissues,  and  if  we  are  timid  in  making  the  application,  the  excite- 
ment caused  by  it  may  cause  the  cancer  to  grow  more  rapidly  than 
we  destroy  it.  I  prefer  a  paste  made  of — R  Chloride  of  Zinc 
(ciystals),  Powd.  Gum  Arabic,  aa.  5ss.;  Powd.  Sanguinaria,  sj.;  rub 
it  up  in  a  mortar,  and  add  Avater  imtil  it  forms  a  paste.  This  is 
spread  on  plaster  leather  a  fourth  of  an  inch  thick,  and  applied  to 
the  growth,  pressing  it  into  every  interstice,  if  it  is  an  open  can- 
cer. The  recommendation  to  push  it  as  rapidly  as  possible  an- 
swers all  questions  as  to  the  frequency  of  application,  and  we  only 
stop  when  we  are  sure  of  the  entire  destruction  of  the  growth. 

If  the  pain  becomes  unbearable,  the  patient  may  be  put  under 
the  influence  of  chloroform,  or  we  may  use  chloral  internally,  or 
a  hypodermic  injection  of  morphia. 

When  we  are  satisfied  the  growth  is  removed,  we  endeavor  to 
heal  the  wound  by  suppuration.  A  dressing  of  a  solution  of 
borax  and  salicylic  acid,  or  of  hydrate  of  chloral,  3 j.  to  water  Oj., 
or  of  the  mild  zinc  ointment,  will  usually  serve  our  purpose  well. 

Arsenic  is  said  to  give  a  painless  cure,  but  this  depends  upon 
the  strength  in  which  it  is  used.  The  majority  of  the  cancer 
recipes  throughout  the  country  contain  arsenious  acid  as  the  active 
ingredient,  and  they  are  sometimes  sold  to  verdant  doctors  at  a 
high  price.  There  is  no  doubt  that  some  of  these  are  very  good, 
as  arsenic  is  one  of  the  agents  known  to  destroy  these  parasitic 
growths.  I  think  its  combination  with  iron  is  one  of  the  best 
forms,  and  I  will  give  directions  for  the  preparation  I  have  usu- 
ally employed.  Take  of  the  hydrate.d  sesqui-oxide  of  iron  a 
sufficient  quantity,  throw  it  on  a  paper  filter,  and  allow  it  to  drain 
until  the  paste  is  of  proper  consistence.  Then  add  lard  one  part 
to  five  of  the  iron,  and  we  have  the  basis  of  our  arsenical  plaster. 


524 


DISEASES     OF     WOMEN. 


If  now  we  have  time,  the  growth  is  slow,  and  not  vascular,  we 
may  add  of  arsenious  acid,  3ij.,  to  this  iron  ointment,  3iv.,  and  the 
application  will  be  almost  painless.  But  if  it  is  necessary  to  de- 
stroy it  more  rapidly,  we  increase  the  proportion,  until  sometimes 
it  is  used  one  part  to  two  or  even  equal  parts. 

The  ointment  is  used  freely,  and  crowded  into  the  open  sore, 
the  dressing  being  made  every  day  ;  gradually  the  growth  loses 
vitality,  becomes  hard  as  if  charred,  and  finally  has  so  separated 
from  the  sound  tissue  that  it  can  be  lifted  with  the  dressing  for- 
ceps. Then  with  a  pair  of  scissors  clip  the  connective  fibres,  tis- 
sue, vessels,  and  nerves,  that  may  hold  it,  and  it  can  be  removed 
"  roots  and  all."  It  will  be  noticed  that  by  this  method  the  growth 
is  desiccated,  and  hardened  into  ajnass,  whilst  \>y  chloride  of  zinc 
it  was  melted  down,  and  passed  off  as  a  species  of  pus. 

In  this  case  it  is  best  to  heal  the  cavity  by  the  dry  process,  in- 
stead of  by  suppuration  as  before,  and  to  accomplish  this  we  dust 
it  at  each  dressing  with  a  very  finely  powdered  sulphate  of  iron. 

The  general  treatment  of  the  cancerous  cachexia  will  vary  in 
different  cases,  the  rule  being  to  give  the  remedy  indicated.  I 
have  seen  most  excellent  results  from  the  administration  of  iodide 
of  potassium,  where  the  patient  had  the  pallid,  leaden-colored 
tongue,  and  the  blue  gums, — the  morbid  process  seeming  to  be 
arrested  for  the  time  being,  and  the  growth  diminishing  in  size. 
So  also  I  have  seen  good  results  from  the  Phytolacca,  when  there 
was  a  tendency  to  glandular  engorgement,  and  from  arsenic  when 
there  was  epithelial  disease.  I  have  given  Donovan's  solution  (in 
minute  doses)  with  Phytolacca  when  there  was  engorgement  and 
tenderness  of  the  superficial  cellular  tissue.  Rhus  has  given  good 
results  when  there  was  great  burning  in  the  cancerous  ulcer  and 

o  o 

an  ichorous  discharge. 

Outside  of  the  selection  of  these  special  remedies,  we  may  use 
the  Hydrastis,  which  has  obtained  quite  a  reputation  with  our 
Homoeopathic  brethren  as  a  specific  to  the  disease.  Or  in  place 
of  this  the  Gallium  Aparine  may  be  employed.  Other  than  these 
we  see  that  waste  and  excretion  are  free,  and  that  digestion  and 
blood-making  are  well  performed.  Among  the  tonics  I  will  sug- 
gest the  use  of  the  syrup  of  the  triple  phosphate  of  quinia,  strych- 
nia, and  iron,  as  especially  useful  in  restoring  innervation,  utthe 
«ame  time  that  it  improves  the  appetite  and  digestion. 


DISEASES     OF     THE     BREAST.  525 

As  a  local  application  to  palliate  the  disease,  relieve  pain,  and 
check  the  rapidity  of  growth,  we  have  seen  that  carbolic  acid 
was  best  for  mucous  membranes,  and  tannic  acid  for  the  disease 
of  the  skin  and  other  parts.  Still  carbolic  acid  may  sometimes 
be  used  in  cancer  of  the  breast,  the  strength  varying  from  a  sat- 
urated solution  to  one  part  to  four  of  glycerine,  or  still  more  di- 
lute. We  use  that  strength  which  best  relieves  the  pain,  and 
checks  growth. 

Tannic  acid  is  used  in  saturated  solution,  either  in  glycerine  or 
water.  It  is  very  freely  soluble,  and  it  is  our  object  to  so  thor- 
oughly tan  the  tissues  that  growth  will  be  next  to  impossible. 
If  it  acts  kindly  the  pain  will  be  mitigated,  the  discharge  greatly 
lessened,  and  the  engorged  tissues  will  be  depleted  of  their  fluids. 

Other  than  this,  a  saturated  solution  of  borax  and  salicylic 
acid  may  be  used  as  a  dressing,  or  a  solution  of  hj'drate  of  chlo- 
ral sj.  to  water  Oj.  These  are  both  good  dressings,  relieving 
pain  and  lessening  or  destroying  the  fetor  of  the  discharges.  I 
do  not  like  permanganate  of  potash  so  well,  but  it  may  some- 
times be  used  with  advantage. 


INDEX. 


79  Abdominal   Manipulation, 

or  hypogastric  touch 66 

444  Abrasion  of  Cervix    Uteri,  230 

114  Abscess  of  Labia, 81 

1085         of    Breasts, 501 

781         of  the  Ovary, 375 

330         Pelvis, 169 

960  Amenorrhea,  .   444 

961  absent  Menstruation,..   444 

967  Symptoms, 446 

968  Causes, 447 

969  Treatment, 447 

973  suppressed    Menstrua- 

tion,     448 

974  Symptoms, 448 

977        Diagnosis, 449 

378         Treatment, 450 

1  Anatomy  of  the  Female  Or- 
gans of  Generation, ....     33 
749  Anteflexion  of  the  Uterus,  362 
749  Anteversion  of  the  Uterus,  362 

751  Causes, 363 

752  Symptoms, 364 

754  Diagnosis, 364 

755  Treatment, 365 

105  Apthae   of  the  Vulva, 79 

49   Bladder,  anatomy  of, 56 

188         removal  of  Calculus  from  107 
233         disease  of,  in  Cystocele,  124 
746  Bond's  Instrument  for  Re- 
tro verted  Uterus, 360 

10-11  Breasts,  Diseases  of, 483 

1044         Anatomy  of, 484 

1080         Inflammation    of, 498 

(526) 


PAfil 

1085  Breasts,  Abscess  of, 501 

1087  Chronic  Abscess  of, 502 

1088  Lactiferous  Swelling  of,  503 
1090         Cellulose  Hydatids  of, . .   503 
1095         Chronic  Mammary   Tu- 
mor,    506 

1100         Irritable  Tumor  of. 507 

1102         Carcinoma,  or  Cancer  of,    508 
66  Broad   Ligaments, 61 

1102  Cancer  of   the  Breast. 508 

1103  Pathology, 509 

1106         Symptoms, 510 

1114  Diagnosis, 512 

1115  Prognosis, 513 

1117         Treatment,    514 

849  Cancer  of  the  Ovary, 401 

851         Symptoms,    402 

844         Diagnosis, 403 

855         Treatment,    403 

480  Cancer  of   the  Uterus, 249 

481  Pathology, 250 

487         Symptoms, 252 

494         Diagnosis, 255 

497  Prognosis, 257 

498  Treatment, 257 

256  Cancer  of  the  Vagina,....   134 

258  Diagnosis, 135 

259  Prognosis, 135 

260  Treatment, 136 

650  Cannula,  double,  for  the  li- 

gation  of  Polypi, 314 

Carcinoma  of  Uterus,  See  Cancer. 
472  Cauliflower  Excrescence  of 

Cervix   Uteri, 243 


INDEX. 


527 


473  Cauliflower  Excrescence  of 
Cervix  Uteri  —  Pathology, 
475         Symptoms  

PAGE 

244 
210 
247 
247 

248 

248 
223 

217 
238 

248 
242 
257 
136 
292 
209 
209 
210 
210 
211 
212 
214 
218 
223 
230 
232 
232 
225 
225 
226 
226 
234 
236 
236 
248 
404 
467 
468 
470 
471 

PAGE 

«[  1023  Chlorosis—  Treatment,  472 
9  Clitoris,  37 

408  Congestion  of  Cervix  Uteri,  209 
410         Symptoms,  209 

476         Diagnosis  .  .    . 

477         Prognosis     .  .  . 

413         Causes,  210 

478         Treatment  

414         Treatment,  210 

479         Excision  of  the  Cervix 
Uteri  in  

634  Conception    with   the    pre- 
sence of  Polypus,  308 

433  Caustic  in  Inflammation  of 
the  Cervix  Uteri  
440         in   Hypertrophy   of  the 
Cervix   Uteri,       .... 

573  Conception,    blighted,  286 

74  Constitutional     effects     of 
Uterine  Disease  64 

464  Corroding     Ulcer     of     the 
Uterus,  240 

462         in    Ulceration    of     the 
Cervix   Uteri 

465         Pathology  240 

478         in    Cauliflower  Excres- 
cence                 ... 

466         Symptoms,  241 

468         Diagnosis,  242 

469         in  Corroding   Ulcer,... 
499         in  Cancer  Uteri 

469          Treatment,   242 

945  Crural    Phlebitis                      435 

261         in  Cancer  Vagina,  .... 
590  Cellular  Polvpus,  

''32  Cvstocele    Vaginal,  1^3 

100  Discharges,  examination  of,     77 
71  Diseases  of  Females,  Path- 
ology of,  63 

408  Cervix  Uteri  Congestion,.. 
410         Symptoms    

75           Diagnosis  of,  64 

417         Inflammation    of,  

104         of  the  External  Organs 
of  Generation,  79 

419            Causes           

164         of  the  Urethra,  96 

426             Treatment 

192         of  the  Vagina,  109 

434         results  of  Inflammation, 
444        Erosion  of  ... 

290         of  the  Perineum,  156 

327         of    the  Pelvic    Cellular 
Tissue,  168 

343         Venereal,  177 

399        of   the  Uterus,  206 

437            Causes 

663             Nervous,  321 

691             Displacements,  333 

439             Treatment,  

772         of  the  Fallopian  Tubes 
and  Ovaries,  372 

955             Functional  diseases  of,  441 
1039             of  the  Breasts,  483 

459            Treatment 

479         Excision  of,  

955  Disorders  of  Menstruation,  441 
691  Displacements  of  the  Uterus,  333 
794  Dropsy    of    the    Fallopian 
Tubes,  373 

856  Child-bed   Fever  

1016  Chlorosis,  

1017        Pathology 

1020        Causes,  

789  Dropsy    (encysted)    of   the 

1021         Svmrotoms.  . 

528 


INDEX. 


559  Dropsy  of  the  Uterus, ....  282 

984  Dysmenorrhea, 453 

985  Neuralgic, 453 

986  Symptoms,   454 

987  Causes, 454 

988  Treatment, 455 

992  Inflammatory,  457 

993  Diagnosis, 457 

994  Treatment, 458 

995  Mechanical, 458 

996  Treatment, 459 

653  Ecraseur   of  Chasaignac.. .  316 

980  Electricity  in  Amenorrhea,  451 

721         in  Prolapsus  Uteri,   .  . .  348 

961         Emansio  Mensium, ....  444 

1024  Emetics  in  Chlorosis, 473 

983  Einmenagogues     in    Ame- 
norrhea,    452 

849  Encephaloid  Cancer  of  the 

Ovary, 401 

122  Encysted  Tumor  of  Labia, .  83 

124             Diagnosis, 84 

126             Treatment,     84 

253         of  the  Vagina, 133 

789         Dropsy  of  the  Ovary,..  377 

725  Episcraphia, 350 

444  Erosion  of  Cervix  Uteri, . .  230 

446  Symptoms, 232  I 

447  Treatment, 232  | 

479  Excision  of  Cervix  Uteri,.  248 
126         of   Encysted   Tumor   of 

Labia, 84 

130         of  Oozing  Tumor, 86 

658         of  Uterine  Polypi, 318 

184         of   Vascular   Tumor   of 

Meatus    Urinarius, ..  104 
161         of    Warty    Tumors    of 

Vulva, 92 

472  Excrescence,    Cauliflower,.  243 
1  External  Organs  of  Genera- 
tion,  Anatomy  of, 33 

104        Diseases  of, 79 

770  Extirpation  of  the  Uterus,  372 

832         in  Ovarian  Dropsy, . . .  392 


PAfl» 

41  Fallopian  Tubes,  Anatomy 

of, 54 

774         Abscess   of, 373 

774         Dropsy  of, 37S 

772         Inflammation  of, 37a 

774         Obliteration   of, 378 

573  False'  Conception, 286 

856  Fever,    Puerperal, 404 

631  Fibrous  Polypus, 305 

848  Fibrous  Tumors  of  the  Ova- 
ries,     401 

586  of  the   Uterus, 291 

587  Pathological    Anatomy 

of, 291 

599         Metamorphosis  and  Dis- 
eases of, 296 

612       '  Symptoms  of  non-pedi- 

culated, 300 

622  Diagnosis, 302 

625  Treatment, 303 

631         Symptoms    of     Pedicu- 

lated, 305 

637  Diagnosis, 310 

646  Prognosis, 312 

647  Treatment, 312 

648  by  Ligation, 312 

653  by  the  Ecraseur, ....  315 

657  by  Torsion, 318 

658  by  Excision, 318 

662  by  the  use  of  Caustic,  320 

264  Fistula    Vesico-Vaginal, . .   137 

265  Causes, 137 

266  Diagnosis, 138 

269         Treatment, 139 

271  Palliative  method, 140 

272  Desault's    method, 140 

273  Cauterization, 141 

276  Suture, 148 

283  Special  Instruments  for 

the  Approximation  of 
the   edges, 147 

284  Anaplasty,  147 

286  Fistula  Recto- Vaginal, 149 

289         Treatment, 150 

292        Case  of  Prof.  Freeman, .   151 


I X  D  E  X  . 


529 


340  Fis;:i'.n   Vos'.co-Uterino, . . .  .  17:; 

341  Utero-intcstinai, 175 

342  llecto-vesical, 17-5 

574  Fleshy    Mole   of  Uterus-,...  287 

950  Fluor  Albus, 4-12 

955   Functional  diseases   of  Ute- 
rus, .  .441 


438   Hypertrophy    of    Comx 

Uleri — Treatment,, 226 


4  Genital     Organs,    anatomy 
of, 

344  Gonorrhea, 

345  different  varieties  of,.. 

348         Symptoms, 

355         Diagnosis.   

958         Treatment 

050  Gooch's    Caiuiula 

448  Granular   Inflammation    of 

Cervix     Uteri, 

1010  Green    Sickness, 

490  Hemorrhage     in     Cancer 
Uteri 

475          in    Cauliflower    Kxcrcs- 
cence, 

in   Corroding  Ulcer, 


34 

177 
178 
17S 
18-2 
183 
314 


407 


635 
143 


247 
242 


in     Inversion     of     the 
Uterus,    .......... 

Uterine  from    Polypus,. 
Venous  from    Vulva,... 


154  Hernia    Vnlvar. 

156         Vaginal, 

559  Hydrometra, 

660 

662 

663 

665 

567 


Varieties,    

Causes,    

Symptoms,    

Diagnosis, 

Treatment,  

677  Hydatids  Uterine, 

12  Hymen , 

196  Persistent, 

193  Imperforate, 

199  Treatment,  

436  Hypertrophy  of  CervixUteri, 

436  Causes, 

438  Symptoms,  

34 


1031    Ilyst 

1032 

1033 

1036 

1037 

1038 


477 


478 

480 
480 
480 


Symptoms, 

Diagnosis, 

Causes. 

Treatment    

508  Ilysterit is,   262 

509  Acute 262 

518         Chronic, 266 

527          Internal,    270 

866          Puerperal, 409 

133  Imperforate    Hymen, 109 

436  Induration  of  Cervix  Uteri,  225 

104  Inflammation  of  the  Vulva, 

superficial, 79 

110  Phlegmonous. 80 

169         of  the    Urethra, 98 

210  of   the    Vagina,  acute..   115 

218  Chronic, 118 

827  of  cellular  tissue  of  Pel- 
vis,      168 

344          Gonorrhea 177 

417  of  the  Cervix    Uteri,...   211 

419  Causes, 212 

422  Symptoms, 214 

426  Treatment,    218 

434  results    of, 223 

508  of    the    Uterus, 262 

509  Acute,    202 

518  Chronic, 200 

527  Internal 270 

866  Puerperal,    409 

772  of  the  Fallopian  Tubes.   373 

776  of  the  Ovaries, 374 

877  of  the  Peritoneum 412 

873  of  the  Veins   and  Lym- 
phatics,     410 

757  Inversion  of  the    Uterus. . .  305 

759         Causes,    366 

760-        Symptoms,   208 

703  Diagnosis, 369 

704  Treatment,   309 


530 


INDEX. 


665  Irritable    Uterus, 322 

666  Diagnosis, 323 

670        Treatment, 324 

157  Itohing  of  the  Vulva, 94 

6  Labia  Majora, 35 

117  Labia,  cohesion    of, 82 

122        Encysted  Tumors   of,..  83 

115        (Edema     of, 82 

127         Oozing  Tumor   of, 85 

138         Thrombus,    or     Sangui- 
neous Tumor  of, 88 

134        Varices  of, 86 

296  Laceration   of  Perineum, . .  156 

296         History, 156 

298  Causes, 157 

299  Means  of  Prevention,. .  158 

301  Consequences    of, 159 

302  Treatment,  159 

306  operation  of  Mr.  Baker 

Brown, 161 

307  Centra-indications     to 

operating, 161 

308  Time  of  operating, 162 

310         Instruments    required,.  162 

312        Mode  of  operating, 163 

314  Division  of  the  Sphinc- 

ter  Ani, 164 

315  Insertion   of   the    Quill 

Sutures, 164 

316  Insertion  of  the  Inter- 

rupted Sutures, 166 

319  Operation     in     recent 

cases, 166 

320  After-treatment, 166 

956  Leacorrhea, 442 

423  from  Cervical  Canal,..  215 

527        Uterine, 270 

218        Vaginal, 118 

648  Ligature  in  Polypus  Uteri,  312 

151  in    Warty    Tumors   of 

Vulva, 92 

184  in  Vascular  Tumor  of 

Meatus  Urinarius,..  104 
772  in  Inverted  Uterus  ...  372 


65  Ligaments  of  the   Uterus,.     61 

66  broad, 61 

67  round, 62 

1041  Mammary,  diseases  of,....  483 

1080  Inflammation    of, 498 

1085  Abscess   of, 501 

1087  Chronic  Abscess  of, 502 

1088  Lactiferous  swelling  of,  503 
1090  Cellulose   Hydatids  of,.  503 

1095  Chronic  Tumor   of, 506 

1100  Irritable   Tumor  of, 507 

1102  Cancer    of, 508 

11  Meatus  Urinarius, 38 

180        Vascular  Tumor  of,...   104 
995  Mechanical   Dysmenorrhea,  458 
990  Menorrhagia,  with  the  dis- 
charge   of    the     normal 
menstrual   fluid, 460 

1000  Symptoms, 460 

1001  Causes. 461 

1002  Treatment, 461 

1007  with    the    discharge    of 

blood    directly     from 
the  uterine  vessels, . .  462 

1008  Symptoms, 462 

1011  Causes, 465 

1012  Diagnosis, 465 

1013  Treatment, 465 

961  Menses,  Abscesses  of, 444 

973         Suppressed, 448 

961  Menstruation,    absent,  ....  444 

973         Suppressed, 448 

999        Excessive, 460 

984        Painful, 453 

975        Vicarious, 449 

944  Milk-leg, 435 

571  Moles, 286 

574        Fleshy, 287 

577        Vesicular, 288 

580        Symptoms, 289 

583  Diagnosis, 290 

584  Treatment, 290 

5  Mons  Veneris, 84 


i  x  D  r:  x . 


531 


08")  Neuralgic    Dysmenorvhea, .  45- 

(J86  '       Symptoms, 44* 

987  Causes, 44'J 

988  Treatment, 450 

663  Nervous    affections    of   the 

Uterus, 321 

8  Nymplue, 36 

177  Occlusion  of  the  Urethra,.  103 

179         Treatment, 103 

198  of  the  Vagina, 113 

199  Treatment, 114 

115  (Edema  of  the  Labia, 82 

121          Inflammatory, 83 

127  Oozing  Tumor  of  Labium,  .  85 

130         Treatment, 85 

457  Os  Uteri,  ulceration  of, ....  235 
423         Dilatation  of,  in  Inflam- 
mation,    214 

43  Ovaries,  ...    55 

776         Inflammation    of, 374 

778  Causes, 374 

779  Symptoms, 374 

781             Terminations,.. 375 

783  Diagnosis, 37(> 

784  Treatment, 37G 

881             Puerperal, 413 

847  Tumors  of, 401 

848  Fibroid   Tumors  of, 401 

849  Cancer    of, 401 

851             Symptoms, 402 

854  Diagnosis, 403 

855  Treatment, 403 

789  Ovarian  Dropsy. 377 

790  Pathology, 

792         Simple   Cysts, 

794         Multilocular,  or  Prolifer- 
ous   Cysts, 379 

796             Structure, 380 

799  Contents, 382 

800  Symptoms, 382 

803            Diagnosis, 383 

813            Treatment, 385 

815         by  Compression  and  Pal- 
pation,    385 


816  Ovarian    Dropsy — by    Tap- 
ping,     386 

810         Tapping  with  Pressure,  388 
820         Tapping    and    Injection 

of    Iodine 888 

826         Artificial   Oviduct, 389 

830         Excision  of  a  portion  of 

the  Cyst, 391 

832         Extirpation, 392 

832  Ovariotomy, 392 

833  reasons  for  and  against,  392 

838  conditions  rendering  it 

justifiable, 394 

839  preparations  for  the  ope- 

ration    395 

840  mode  of  operating, 396 

843         dangers  to  be  apprehend- 
ed after, 399 

776  Ovaritis, 374 

70  Pathology,  Uterine, 63 

62  Pelvic  Fascia, 60 

330  Pelvic  Abscess, 169 

327         Cellulitis, 168 

327         History, 168 

329  Causes, 168 

330  Terminations, '. . .  169 

331  Duration, 170 

332  Symptoms, 170 

333  Diagnosis, 171 

334  Treatment, 171 

338         Fistulous    passages    re- 
maining   after, 173 

340         Cases  of, 173 

52  Perineum, 58 

296  Perineum,  Laceration  of,..  156 

877  Peritonitis,    Puerperal,....  412 

714  Pessaries, 343 

944  Phlebitis,   Crural,   435 

873         Uterine, 410 

944  Phlegmasia   Dolens, 435 

945  Pathology  of, 436 

946  Symptoms, 437 

950  Diagnosis, 439 

951  Treatment, 439 


532 


INDEX. 


f     110  Phlegmonous  Inflammation 

of    Labia, 80 

111  Causes, 80 

112  Diagnosis 80 

113  Treatment, 81 

550  Physometra 279 

554         Symptoms, 281 

556  Diagnosis, 281 

557  Treatment, 282 

631  Polypus  Uteri — Symptoms..   305 
637         Diagnosis, 310 

646  Prognosis, 312 

647  Treatment, 312 

648  by  Ligation. 312 

653         by    the  Ecraseur. 315 

657  by   Torsion, 318 

658  by  Excision, 318 

662         by  the  use  of  Caustic,. .   320 

693  Procidentia    Uteri, 334 

693  Prolapse  of  the  Uterus,...   334 

697         Causes, 334 

703         Symptoms, 339 

709  Diagnosis, 340 

710  Treatment, 341 

711  by  rest  iii  the  horizontal 

position, 341 

712  by  Astringent  Injections,  341 

714         Pessaries, 343 

718        Rational  Method 346 

721         Galvanism, 348 

724  Perineal  Supporter, 349 

725  Episcraphia, 350 

231  Prolapse  of  Vagina, 122 

232  Prolapsus  Vesicae. 123 

157  Pruritus  of  Vulva, 94 

158  Symptoms, 94 

i60         Treatment, 95 

856  Puerperal   Fever, 404 

858        Causes, 404 

864        Pathological  Anatomy,.  407 
866         Puerperal  Endometritis,  409 
873         Inflammation  of  Veins  & 

Lymphatics  of  Uterus,  410 
877         Inflammation     of     the 

Peritoneum, 412 


f     881  Puerperal  Fever— Puerperal 

Ovaritis,   413 

885  Pathological  changes  in 
other  portions  of  the 
system, 414 

904         Secondary  terminations,  420 

907  Symptoms, 121 

908  Symptoms  of  the  Inflam- 

matory form, 421 

913         Symptoms    of    the    Ty- 


phoid  form,  

423 

921 

Diagnosis,  

42tj 

920 

Prognosis  

428 

927 

Treatment,  

428 

286 

Recto-Vaginal  Fistula, 

149 

289 

Treatment,  

150 

°92 

Case  of  Prof.  Freeman, 

151 

240 

Rectocele,  

128 

727 

Retroflexion  of  Uterus,  .... 

350 

727 

Retroversion  of  Uterus,... 

350 

729 

Causes,  

352 

730 

Svmptoms,  

352 

735 

355 

738 

Treatment,  

356 

676 

Rheumatism  of   Uterus,... 

326 

677 

Causes,  

327 

678 

Symptoms,  

327 

683 

Influence  on  the  progress 

of  Pregnancy,  

329 

684 

Influence  on  Labor,  .  .    . 

330 

686 

331 

687 

Treatment,  

331 

85 

Ricord's    Speculum,  

71 

296 

Rupture  of   Perineum,  .... 

156 

293 

154 

138  Sanguineous  Tumor  of  the 

Labia, 88 

140  Diagnosis, 89 

141  Treatment, 89 

849  Scirrhus  of  the  Ovary, 401 

489        of  the  Uterus, 249 

100  Secretions,  examination  of,  77 

88  Simpson's  Uterine  Sound,.  72 


i  x  D  i:  x . 


533 


84  Speculum,   use  of, 

85  P.  i  cord's 

85         Ferguson's, 

175  Stricture  of  the    Urethra,.. 

170         Treatment, 

202  Stricture  of  the  Vagina,... 

205         Treatment. 

304  Syphilis, 

360          Stages  of. 

3G9         Inoculation, 

370  Simple  I  hancre,    

371  Indurated,  or  lluntcrian 

Chancre .... 

372  Phagedenie  Chancre,... 
377          Secondary  Symptoms,.. 

382  Syphilitic  Vegetations.. 

383  Mucous  Tubei'cles. 

385          Diagnosis, 

388         Treatment  of  Primary. . 
392         Treatment  of  Secondary, 

816  Tapping  in  Ovarian  Dropsy. 

819  with  Pressure, 

820  with  Injection  of  Iodine. 
138  Thrombus,    or  Sanguineous 

Tumor  of  the  Labia, . .  . 

140  Diagnosis, 

141  Treatment, 

657  Torsion    for   removal    of 

Polypi, 

80  Touch,  as  a  means  of  Diag- 
nosis,   

60  Transversus   Perinaji, 

55  Triangular  Ligament 

122  Tumors,    Encysted,    of    the 

Labia. 

127         Oozing  of  the  Labia.. . . 
138         Sanguineous  of  the  La- 
bia,   

148         Warty,  of  the  Vulva,.. 
180         Vascular,  of  the  Meatus 

Urinarius, 

253         of  the  Vagina, 

586         Fibroid,  of  the  Uterus, . 
612         Non-pediculated, 


-jOl  Tumors— Pedicnlated(Po!y- 

pi,) 305 

847         of  the   Ovary, 401 

550  Tympanitis,  Uterine, 279 

4(H  Ulcer,   Corroding. 210 

454  Ulceratiou    of    the    Cervix 

Uteri, 20  i 

4-3         Symptoms 2.r',r> 

459          Treatment, 206 

40   Urethra '36 

188         Dilatation   of.  for  remo- 

val    of  Calculi, 107 

168         Inflammation  of. 98 

180         Tumors  at  orifice  of..  ..  104 

175          Stricture  of, 102 

185         Foreign  bodies   in, 100 

1C.8  Urcthritis, 98 

109          Symptoms, 98 

]70         Treatment 99 

527   Uterine  Leucorrhca, 270 

559         Dropsy, 282 

873         Phlebitis, 410 

88         Sound.   .' 72 

550         Tympanitis, 279 

23  Uterus,    Anatomy  of, 43 

749         Anteilexion    of, 362 

749         Anteversion  of, 362 

480          Cancer    of, 249 

480          Carcinoma  of, 249 

472         Cauliflower  Excrescence 

of, 243 

464          Corroding  Ulcer  of,....  240 

399         Diseases  of  the, 206 

69]          Displacements  of  the,..  333 

559         Dropsy  of  the, 282 

771         Extirpation  of  the, ....  372 

586         Fibroid   Tumors   of, 291 

508  Inflammation  of, 262 

509  Acute, 262 

518  Chronic, 266 

527  Internal, 270 

757         Inversion  of, 365 

665         Irritable, 322 

571  Moles  and  Hydatids  of,  280 


INDEX. 


[     631  Uterus,  Polypus  of, 305 

693        Prolapse  of, 334 

727        Retroflexion  of, 350 

727         Retroversion  of, 350 

676        Rheumatism  of, 326 

192  Vagina,  Diseases  of,.      ,.  109 

256         Cancer  cf,..    ,.,..    .  134 

210        Inflammation    of, 115 

210            Acute, 115 

218             Chronic,  118 

192-198  Occlusion  of  the, 109 

231  Prolapse  of, 122 

232  the  Anterior  Wall,..  123 
240            the  Posterior  Wall,..  128 
249            Entire  Circumference,  131 

293        Laceration  of, 154 

202         Stricture    of, 113 

253        Tumors  of, 133 

232  Vaginal  Cystocele, 123 

233  Symptoms, 123 

234  Diagnosis, 124 

235  Treatment, 124 

80-84  Vaginal   Examination, 67 

218        Leucorrhea, 118 

240  Rectocele, 128 

241  Causes, 129 

242  Symptoms, 129 

244  Diagnosis, 130 

245  Treatment, 130 

210  Vaginitis,  Acute, 115 

212  Causes, 116 

213  Diagnosis, 116 

214  Treatment, 117 

218         Chronic, 118 

221             Symptoms, 118 

223  Diagnosis, 119 

224  Treatment, 120 

134  Varices  of  the  Labia, 86 

135  Causes, 87 

136  Treatment, 87 

577  Vesicular    Mole, 288 

264  Vesico- Vaginal  Fistula,...  137 

265  Causes, 137 


266  Vesico-Vaginal    Fistula — 

Diagnosis, 138 

269        Treatment, 139 

271  Palliative  Method, 140 

272  Desault's   Method, 140 

273  Cauterization, 141 

276         Suture, 143 

283  Special  Instruments  for 

Approximation  of  the 

Edges, 147 

284  Anaplasty, 147 

340  Vesico-Uterine   Fistula,...  173 
873  Veins  of  Uterus,  Inflamma- 
tion of, 410 

10  Vestibule, , 38 

975  Vicarious    Menstruation, . .  440 

104  Vulva   Superficial,    Inflam- 

mation  of, 79 

105  Appearances, 79 

106  Causes, 79 

107  Treatment,  79 

110  Phlegmonous  Inflamma- 

tion of, 80 

111  ,     Causes, 80 

112  Diagnosis, 80 

113  Treatment, 81 

143         Venous  Hemorrhage  from  90 

148  Warty  Tumors  of, 92 

149  Symptoms,  92 

150  Causes,   92 

151  Treatment, 92 

157  Pruritus  of, 94 

158  Symptoms, 94 

160             Treatment, 95 

122         Tumors  of  the, 83 

154  Vulvar  Enterocele, 93 

155  Treatment, 93 

148  Warty  Tumors  of  the  Vulva,     92 

149  Symptoms, 92 

150  Causes, 92 

151  Treatment, 92 

253        of  the  Vagina, 133 

956  Whites, 442 


COMPLETE 

DESCRIPTION  AND  PRICE  LIST 


OF 


MEDICAL  BOOKS 


PUBLISHED  AND  FOR  SALE 


JOHN  M.  SCUDDER, 

228  COURT  STREET,  CINCINNATI,  O. 

1893 
Any  book  in  this  list  sent  post-paid  on  receipt  of  price. 


TT  S  a  school  of  medicine  we  profess  to  have  a  distinctive  practice,  unlike 
<§/l  either  our  old  school  or  homeopathic  neighbors.  We  claim  to  use  differ- 
ent remedies,  or  in  different  form  and  dose,  and  for  different  effects.  We 
boldly  claim  a  more  successful  practice  than  either  of  our  competitors,  and  this 
claim  can  only  be  based  upon  different  principles,  a  different  therapeutics,  and 
a  different  materia  medica. 

We  must,  therefore,  have  distinctive  books  which  clearly  state  our  methods 
of  practice.  Old-school  works  will  not  serve  this  purpose,  neither  will  homeo- 
pathic. With  the  pretensions  we  make,  if  we  can  not  show  that  we  have  such 
works,  and  depend  upon  them,  we  are  frauds  of  the  first  magnitude. 

In  the  early  days  of  Eclecticism,  the  need  of  text-books  was  clearly  seen, 
and  great  sacrifices  were  made  to  furnish  them.  The  writers  toiled  without 
pay,  and  to  publish  the  earlier  works  they  practiced  the  most  rigid  economy  for 
years  to  command  the  money.  By  these  means  we  had  Beach's  works,  Jones 
and  Morrow's  Practice,  King's  Dispensatory,  and  some  others.  The  making 
of  books  was  not  an  easy  nor  a  profitable  job. 

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ECLECTIC  PRACTICE  OF  MEDICINE, 

BY  JOHN  M.  SCUDDER,  M.  D. 

The  best  recommendation  of  this  work  comes  in  the  statement  "  thirteenth 
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mSgTffi  PRACTISE  IN  DISEASES  OF  CHILDREN. 

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Date  Due 


CAT.    NO.    23    233  PRINTED    IN    U.S.A. 


7  '3 


WP100 
Sl*36p 

1891 

Scudder,  John  M 

Practical  treatise  on  the 
diseases  of  women. 


WP100 
SU36p 

1891 
Scudder,  John  M 

Practical  treatise  on  the  diseases  of 
women. 


CALIFORNIA  COLLEGE  OF  MEDICINE  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVlNfc 

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